The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61:927-934 (2006)
© 2006 The Gerontological Society of America
Nutritional Risk and Low Weight in Community-Living Older Adults: A Review of the Literature (1995–2005)
Carolyn Thompson Martin,
Jeanie Kayser-Jones,
Nancy Stotts,
Carol Porter and
Erika Sivarajan Froelicher
1 Department of Physiological Nursing, University of California San Francisco.
2 Department of Nutrition and Food Services, University of California San Francisco Medical Center.
Address correspondence to Carolyn Martin, PhD, Demergasso-Bava Hall, 801 West Monte Vista Ave., Turlock, CA 95382. E-mail: carolynmartin{at}alumni.ucsf.edu
 |
Abstract
|
|---|
Although many studies have examined weight loss and low weight in institutionalized persons, there has been little research exploring the community-living older adult's nutritional risk. The purpose of this literature review (1995–2005) is to describe our current understanding of nutritional risk and low weight in community-living older adults 65 years old and older. Computerized database searches and footnote reviews were used to find published studies on nutritional risk and low weight. Twenty-two research articles are reviewed and summarized. Each study was reviewed according to preset criteria.
AMERICANS older than 65 years make up the fastest growing segment of the population, which will reach 69.4 million by 2030, placing a significant demand on the health care delivery system (1). Although malnutrition is believed to be relatively rare (10%) (2), nutritional risk is more common (25%–65%) (3). Malnutrition in older adults 65 years old or older is a body mass index (BMI) less than or equal to 18.5 (kg/m2) and severe malnutrition is a BMI less than 16 kg/m2 (4). Nutritional risk is a term used to indicate risk for low weight and poor nutritional health (BMI < 24 kg/m2) (4). The diagnosis "failure-to-thrive" is frequently used to identify older adults who lose weight due to unknown etiology. Failure-to-thrive is the transition from robust health to frailty (5). Nutritional frailty refers to the functional impairment in elderly persons that is a consequence of unintentional weight loss that result in decreased lean body mass and strength (sarcopenia) (6).
There is no consensus in the literature with respect to the definition of underweight or overweight for older adults (7). Unintentional weight loss that increases nutritional risk is considered a loss of 1%–2% per week or 5% per month (8). Studies differ as to the clinical significance of unintentional as compared to intentional weight loss in terms of morbidity and mortality (9). Older adults with the lowest mortality rate and best functional ability have a BMI between 22 kg/m2 and 30 kg/m2 (for women) or a BMI between 23 kg/m2 and 30 kg/m2 (for men) (10). Cause for concern in older adults is a BMI less than or equal to 21 kg/m2 (11).
Nutritional frailty has been studied mostly in long-term care facilities due to easy access to data. These studies associate unintentional weight loss and low weight with increased mortality, early admission to nursing homes, longer and more frequent hospital stays, and increased health care cost (12–15).
Weight loss, especially unintentional, is not a normal part of aging and usually represents an underlying disease process (6). Recent unintentional weight loss is fairly common among community-dwelling elderly persons and needs to be considered to be an adverse health indicator even among obese elderly persons (16). In older adults the loss of body weight, apart from intentional weight reduction in overweight and obese individuals, usually leads to poor health outcomes (9,17–19).
Many health care providers (HCPs) fail to identify and treat unintentional weight loss in this population. One study found that less than 5% of older adult medical outpatients with significant weight loss are diagnosed with low weight, which resulted in a delay of therapeutic intervention (20). Management of unintentional weight loss is directed at treating underlying causes and providing nutritional support (21). Furthermore, in older adults social and environmental factors are crucial aspects of care (22).
Here we review the current research on nutritional risk and low weight in community-living older adults, age 65 years and older. This review will increase our understanding of the factors that contribute to unintentional weight loss and low weight and explain the difficulty associated with identifying independent-living older adults who are at risk for poor nutrition. Weight loss in obese and overweight elderly persons, as well as treatment of unintentional weight loss, are beyond the scope of this article.
Two strategies were used to find published studies on unintentional weight loss and low weight: (i) computerized database searches (PubMed, Medline, and EMBASE) and (ii) footnote reviews. Studies were limited to the past 10 years to allow for a current review of research and due to limited research on community-dwelling, older adults prior to 1995.
Studies were included if they met the following criteria: (a) sample included adults 65 years and older; (b) the research was published between 1995 and 2005; (c) the journal was accessible in the English language; (d) the sample was community-living; (e) the data were collected in a noninstitutional community setting; and (f) the data described nutritional risk (BMI < 24 kg/m2) and low weight among older people (4).
Research that studied acute and chronic disease (e.g., dementia) in relation to weight loss or low weight was excluded. Furthermore, research that investigated assessment tools, diagnostic strategies, and interventions were also excluded. Twenty-two studies met the criteria (see Table 1). The number of study participants ranged from 22 to 7419, with an age range from 50 to 92 years. The majority of participants were Caucasian, above poverty level, and female. Participants were from both urban and rural settings.
View this table:
[in this window]
[in a new window]
|
Table 1. Summary of Literature Describing Nutritional Risk and Low Weight in Community-Living Older Adults (1995–2005).
|
|
The following research data describe findings that include the entire population studied. When possible, details are given on those participants who experienced weight loss and low weight.
|
NUTRIENT INTAKE
|
|---|
Researchers (23) studied low-income individuals (n = 200), most of whom participated in or were eligible for food stamps. The researchers found that, although there were no significant differences in food group or nutrient intake between low-income participants, overall, they did not meet DRI standards for many nutrients and energy (mean ± SD = 1314 ± 489; range 556–3649). This group consumed less bread, cereal (bread/cereal/pasta; mean ± SD = 31.9 ± 8.5), and milk products (milk/cheese/yogurt; mean ± SD = 1.9 ± 1.2) than is recommended by the U.S. Dietary Guidelines. Dietary intakes of calcium, vitamin E, folate, magnesium, and fiber were below the DRI for these nutrients.
Another study (24) conducted in-home interviews (n = 470) and collected information from diet records and the Nutritional Screening Initiative (NSI) Checklist (n = 261). Less than 20% (n = 41) consumed adequate levels of 16 or more of the 19 nutrients measured, and few of the participants with low nutrient intake consumed supplements.
|
DIETARY BELIEFS
|
|---|
McKie and colleagues (25) found that few elderly persons (n = 152) thought that there were any special nutritional precautions that older people should follow to safeguard or to improve their health in old age. They also reported that dietary beliefs in older adults are established in childhood and were influenced by lifetime experiences. Callen and Wells (26) demonstrated similar results and reported that old-old adults (age 80 years or older) believe that they are doing well nutritionally.
Another study suggests that older adult women participate in health-promoting behaviors (such as nutrition) for health enhancement and maintenance reasons (27). These women (n = 107) reported benefits from health-promoting lifestyles such as better psychological well-being, increased ability to cope with aging, improved function, and management of health problems (Health Promotional Lifestyle mean ± SD = 2.8 ± 0.4, range 1.6–3.7).
|
RESTRICTIVE DIETS
|
|---|
One study associated with the Women's Health Initiative investigated (n = 7419) older adult women's low-fat diet practices and found that these practices were widespread in this population (28). A questionnaire was used to assess foods eaten during the past 3 months. Their low-fat choices had substantial effects on energy and nutrient estimates (p <.05 larger decrease in estimates of percentage of energy from fat). Black and Hispanic women and women of lower socioeconomic status reported significantly fewer low-fat-diet practices than did Caucasian women or women of higher socioeconomic status (28). Another study reported that many older adults older than 80 years avoided fat and cholesterol in their diet (26).
Clarke (29) found that older adult women (n = 22) were not happy with their current weight. Women express the reason for intentional weight loss as being necessary for health benefits, but the author concluded that appearance is the key motivation. This study investigated how socialization, fat phobia, and the consumer culture dominate the thoughts of older women. Clarke (29) concluded that weight continues to be a concern for women as they age.
|
NUTRITIONAL RISK
|
|---|
Marshall and colleagues (30) used the (NSI) Checklist and a food questionnaire, and found that Hispanic elderly persons (n = 1006) in rural settings had a higher prevalence of nutritional risk factors than did non-Hispanic whites (NSI nutritional risk mean score: Hispanic men, 3.14; women, 4.13; NSI mean score: non-Hispanic men, 3.15; women, 3.48 with a score of 3–5 reporting moderate nutritional risk). Miller and colleagues (31) used in-home interviews and the NSI Checklist to examine inner-city older African Americans (n = 415) and found them to be at high nutritional risk (27% living in North St. Louis [NSL] and 17% living in East St. Louis [ESL] had a BMI less than 24 kg/m2; 48% in NSL and 66% in ESL had a high-risk NSI score [
6]). Three quarters of the participants ate alone most of the time and demonstrated high risk from eating few fruits, vegetables, and milk products; taking three or more drugs per day; having difficulty shopping and cooking for themselves; and suffering tooth or mouth problems that impair eating. In this study, poverty was clearly a major risk factor for nutritional problems (income <$7,500/year: 53% in NSL and 68% in ESL). This study highlighted the role of poverty and isolation as a major nutritional risk factor.
Other researchers used the NSI Checklist to determine nutritional risk (32). They found that men (32%) had 90% greater risk for poor nutritional status than did women, even while receiving Meals-on-Wheels food services (five home-delivered meals per week). These participants (n = 230) had improved energy and nutrient intake.
Another study (33) reported that eating problems, poor appetite, income <$6,000/year, eating alone, and depression were significant predictors of functional limitations in older rural adults (n = 2500). They also found that those participants who were male and those having recent weight loss (4.5 kg in 6 months) were predictors of increased health care cost.
Using in-home interviews and dietary recall, other researchers investigated risk factors prospectively for institutionalization of frail elderly participants (n = 288). This cohort study (34) followed participants at 3 and 5 years. Twenty-two percent were receiving home help services (such as home-delivered meals). The researchers concluded that those participants who were institutionalized were more likely to be male and functionally impaired. A weight loss of 4.5 kg during the year preceding the baseline interview significantly predicted the risk of institutionalization (p <.05). The recommended intake for protein was not met by 53% of the study participants.
Another prospective study investigated frail elderly persons (n = 367) using in-home interviews (35). The participants were contacted every 3 months for 18 months to determine quality of life (QOL). That study was the first to investigate nutritional risk associated with self-reported QOL over time in older adults, and it concluded that nutritional risk is a predictor of decline in health-related QOL (35).
|
NUTRITIONAL ADVICE
|
|---|
Older adults (n = 152) reported skepticism as to the reliability of nutritional information (25). Attitudes about nutritional advice were influenced by: (a) lifetime experiences of looking after themselves (this was validated by the fact that they had survived to their current age without harm); (b) conflicting advice (one day they are told something is good for them and later told that it is not); (c) experience of others following advice (the older participants knew of others that had eaten all the recommended foods but had disease, such as cancer, anyway); and (d) advice as experimentation (participants felt the advice was based on uncertain foundations, and that they would not know until many years later if it was factual) (25). Green and Adderley-Kelly (26) found that elderly persons have a major interest in information on nutrition and are more interested in health promotion than in topics on disease and prevention. Information was commonly obtained from nonmedical sources such as magazines and the media (25).
|
HEALTH, AGING, AND BODY COMPOSITION STUDY
|
|---|
The Health, Aging, and Body Composition (ABC) study was designed to investigate functional decline in healthier older persons (n = 2932). One analysis of the data gave insight into the role that weight loss has on functional decline (37). Overall, 30% of the participants developed mobility limitations. Participants who had intentional weight loss and weight fluctuation with any intention had increased risk for decreased mobility. This study, which included 610 (44%) elderly persons with a BMI < 25 kg/m2, reported that persons who intentionally lost weight and had weight fluctuation with any intention increased their risk of limited mobility.
Lee and colleagues (38) investigated weight loss intention in these participants. Twenty-seven percent of the participants (n = 2932) reported current intention to lose weight, with only 67% of this sample having an indication for weight loss. It was surprising that, in the group of participants with a BMI between 18.5 and 24.9 kg/m2, 38 (13.1%, n = 291) of them lost weight intentionally and 117 (42.1%, n = 278) did so unintentionally.
In another study, Lee and colleagues (39) reassessed participants (n = 522) in the ABC study after 6 months who had reported a ±5% weight loss. Most participants resolved their weight loss within the 6 months. Those participants who reported unintentional weight loss appear to be less likely to regain the weight. The study included 17 (27%) participants with a BMI < 25 kg/m2 reporting intentional weight loss and 66 (61%) with unintentional weight loss.
Newman and colleagues (40) investigated weight loss and gain in this cohort. They found that weight gain and loss was common. Of those participants with a BMI < 25 kg/m2 (n = 63), 27% intentionally lost weight and 54% wanted to lose more. Sixty-one percent of participants with a BMI of <25 kg/m2 (n = 108) lost weight unintentionally. Most importantly, weight loss (despite weight gain) may accelerate sarcopenia in these participants.
|
NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY II MORTALITY STUDY
|
|---|
Older adults (n = 5838) were asked questions about unintentional weight loss within the past 6 months (22). The researchers reported that recent unintentional weight loss was common among community-dwelling older adults (13% over past 6 months) and was associated with characteristics of poor health and independently associated with mortality (24% increase). Social contacts were examined in a sample of this cohort (n = 3194) (41). Researchers reported that dietary intake is affected by demographic, lifestyle, and social factors including frequency of social contact. Community outreach and screening may result in social and health benefits in this population.
|
SURVEY IN EUROPE ON NUTRITION AND THE ELDERLY: A CONCERTED ACTION STUDY
|
|---|
Two studies reported on diet and nutrition in a large, elderly, European cohort (n = 2586). These elderly participants were studied prospectively for 10 years. Researchers reported that undernutrition was prevalent in the participants (44%), but was not a major problem for the surviving cohort (42). There were several factors that increased mortality, including low-quality diet (43). Risk factors for undernutrition, in a smaller sample (n = 843), included a reduction in total energy protein which jeopardized the individuals supply of micronutrients and contributed to continued weight loss (42).
|
DISCUSSION
|
|---|
Over the last decade few studies have examined nutritional risk and low weight in the community-living older adult population. Multifactorial issues that contribute to nutritional risk and malnutrition make it difficult to study (Figure 1). It is apparent that weight loss and nutritional risk are common in this population and can be associated with adverse outcomes. More research is needed to differentiate between unintentional and intentional weight loss, and to determine the significance of weight loss relative to clinical outcomes in older adults. Furthermore, more data are needed clarify: (a) weight loss risk in low weight versus obese older individuals, and (b) the role of social and environmental factors in weight loss.
The use of a descriptive and cross sectional design is appropriate to investigate this topic, because there has been little research. Using a descriptive study is a good approach to developing hypotheses for future studies. The major concern with cross-sectional studies is the difficulty with establishing causal relationships. A qualitative approach allows a better understanding of the role of human behavior in the older adult's dietary practices (44).
Many studies (23,24,30,32) used the NSI Checklist to screen for nutritional risk in participants. This Checklist is a one-page screening tool designed to identify eating, economic, and lifestyle behaviors that may contribute to the development of nutritional problems (45). This tool is not a diagnostic device, but is a measure of potential nutritional risk (45). It has demonstrated poor psychometric properties, with low sensitivity and specificity; as would be expected in a screening instrument (45). The NSI Checklist has a reasonable positive predictive value (38%) for those persons whose estimated nutritional intake falls below the Recommended Dietary Allowances (RDA) (46).
An important limitation of our review is that most of the studies had a small sample size and lacked diversity in ethnicity and gender. Most participants in these studies were recruited from limited areas, with the exception of four large multicenter studies. One study on women's health, even though it was nationally advertised, resulted in participants who were female, Caucasian, well educated, and with a relatively high socioeconomic status (28). Even though the ABC study had a large sample size, it investigated a cohort with a restricted age range and functional health status. These restrictions may have resulted in the participants having a better ability to maintain a stable weight than those individuals who were excluded. Studies that collected data outside of the United States may have limited generalizability due to different health care systems and social and/or cultural issues (25,29,34,35,42,43).
Many of these studies did not discuss recruitment procedures. It is difficult to recruit community-living older adults due to multiple factors, including chronic and acute disease states, difficulties with transportation, problems with mobility, financial limitations, and possibly the lack of social support for taking part in research studies. Because participants with poorer cognitive and nutritional status may not participate, there may be an underestimation of the true risk in the older population, leading to limits in generalization to the entire population.
Avoidance of bias in sample selection would be difficult in older adults. Those individuals who agree to be interviewed may be healthier, better educated, have better cognitive function and improved nutritional status, and may be more interested in research. For instance, one study using a convenience sample reported that selection bias may have resulted from using older adults known to parish nurses (26).
Conducting field studies usually requires that the measurement be noninvasive and suitable to community settings; this requirement may limit data collection. Other issues related to data collection are poor dietary recall and use of self-reported height and weight, weight change, and weight change intention, because of memory deficits. If tool self-administration is required, the recording process may be compromised do to fine motor difficulties and limited vision (24).
Evidence suggests that older adults do not think they are at risk for inadequate nutrition (25,26), even though several studies in this review report this as a problem. Data show that older people do not consume the recommended DRI standards for most nutrients, protein, and caloric food group servings (23,24,42). Older adults are interested in nutritional information and health promotion (25,26,36) but are distrustful of nutritional advice (25), which may result in fewer people following strategies to avoid nutritional risk. HCPs must know current nutritional information and assist older adults in understanding its relationship with health maintenance.
Clarke (29) concluded that weight continues to be a concern for women as they age; giving us insight into possible resistance to weight gain by some older women, which may result in resistance to advice given by an HCP to avoid further weight loss. Lee and colleagues (38) reported that elderly individuals are intentionally losing weight without an indication for weight loss. Low-fat intake was common among older women resulting in a decrease in energy intake which compromised their functional capacity (28). HCPs must keep fat avoidance in mind as they interview their low weight female patients. Lee and colleagues (38) suggest that attention needs to be focused on the necessity and efficacy of specific strategies for weight loss in older adults.
There is a need for carefully designed population surveys with appropriate representative sampling to define and describe nutritional risk and low weight in older adults. Prospective longitudinal studies could clarify the development of this phenomenon over time. More studies that include diversity with respect to race and gender would increase our understanding of weight loss and low weight in these older adults. Tools that assist with identifying people of ethnically diverse communities need to be a priority for development and evaluation.
More studies that investigate women's knowledge, attitudes, and beliefs, as well as perceptions of their physical appearance, are needed. Clarke (29) recommends examining race, sexual orientation, and the impact of significant others in shaping perceptions about weight and dieting. More investigation into social and/or cultural issues in older individuals may assist with early recognition of impending poor nutrition (41).
Little research has examined QOL over time in community-living older adults (47). Future nutrition intervention studies in older adults need to include QOL measures as viable outcomes (35). Earlier detection of nutritional problems provides the opportunity for interventions before low weight affects the overall health and QOL in old age (26).
Research is needed to investigate whether HCPs know the DRI standards or have a practical understanding of tools that could help people achieve these standards. It would be important to ask what elderly persons believe would best assist them with nutritional health.
Weight loss is a sentinel event with devastating consequences among community-living elderly persons. The goal is to modify nutritional risk factors to assure independent living, to delay institutionalization, and to decrease the risk of morbidity. Our knowledge of nutritional status of older adults is far from complete. There is a need for further research that would increase our understanding of the factors that contribute to weight loss and low weight for the development of appropriate preventive and treatment strategies to improve the health of the older adult.
|
Acknowledgments
|
|---|
This work was supported by a grant from the National Institutes of Health, Ruth L. Kirschstein National Research Service Award Individual Fellowship, Grant NR009165-01.
|
Footnotes
|
|---|
Decision Editor: Darryl Wieland, PhD, MPH
Received November 1, 2005
Accepted March 13, 2006
|
References
|
|---|
- U.S. Census Bureau., 2000;. United States Census 2000. Available at: http://www.census/gov/main/www/cen2000.html (Last accessed: 06-25-06).
- Edington J, Kon P, Martyn C. Prevalence of malnutrition in patients in general practice. Clin Nutr. 1996;15:60-63.[Medline]
- Keller H, McKenzie J. Nutritional risk in vulnerable community-living seniors assessed. Can J Diet Pract Res. 2003;64:195-201.[Medline]
- Nutritional Screening Initiative. Incorporating Nutrition Screening and Intervention Into Medical Practice. Washington, DC: Nutrition Screening Initiative; 1994.
- Verdery R. Failure to thrive in older people. J Am Geriatr Soc. 1996;44:465-466.[Medline]
- Bales C, Ritchie C. Sarcopenia, weight loss, and nutritional frailty in the elderly. Annu Rev Nutr. 2002;22:309-323.[Medline]
- Heiat A, Vaccarino V, Krumholz H. An evidence-based assessment of federal guide-lines for overweight and obesity as they apply to elderly persons. Arch Intern Med. 2001;161:1194-1203.[Abstract/Free Full Text]
- Moylan K, Lin T. The Washington Manual Subspecialty Consult Series Geriatrics Subspecialty Consult. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
- Wallace J, Schwartz R. Involuntary weight loss in elderly outpatients. Clin Geriatr Med. 1997;13:717-735.[Medline]
- Tayback M, Kumanyika S, Chee E. Body weight as a risk factor in the elderly. Arch Intern Med. 1990;150:1065-1072.[Abstract/Free Full Text]
- Thomas D, Ashmen W, Morley J, et al. Nutritional management in long-term care: development of a clinical guideline. J Gerontol Med Sci. 2000;55A:M725-M734.[Abstract/Free Full Text]
- Committee on Nutritional Service for Medicare Population, Food and Nutrition Board. The role of nutrition in maintaining health in the nation's elderly: Evaluation coverage of nutrition services for the Medicare population. Washington, DC: National Academies Press; 2000.
- Egbert A. The dwindles: Failure to thrive in older patients. Nutr Rev. 1996;54:S25-S30.[Medline]
- Wallace J, Schwartz R, La Croix A, Uhlmann R, Pearlman R. Involuntary weight loss in older outpatients: incidence and clinical recognition. J Am Geriatr Soc. 1995;43:329-337.[Medline]
- Van Nes M, Herrmann F, Gold G, Michel J, Rizzoli R. Does the Mini Nutritional Assessment predict hospitalization outcomes in older people? Age Aging. 2001;30:221-226.[Abstract/Free Full Text]
- Sahyoun N, Pratt A, Anderson A. Evaluation of nutrition education interventions for older adults: a proposal framework. J Am Diet Assoc. 2004;104:58-69.[Medline]
- French S, Folsom A, Jeffery R, Williamson D. Prospective study of international weight loss and mortality in older women: the Iowa Women's Health Study. Am J Epidemiol. 1999;149:504-514.[Abstract/Free Full Text]
- Yaari S, Goldbourt U. Voluntary and involuntary weight loss: associations with long term mortality in 9228 middle age men and elderly men. Am J Epidemiol. 1998;148:546-555.[Abstract/Free Full Text]
- Wannamethee S, Shaper A, Lennon L. Reasons for intentional weight loss, unintentional weight loss, and mortality in older men. Arch Intern Med. 2005;165:1035-1040.[Abstract/Free Full Text]
- Wilson M, Vaswani S, Liu D, et al. Prevalence and causes of undernutrition in medical outpatients. Am J Med. 1998;104:56-63.[Medline]
- Huffman E. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician. 2002;54:640-650.
- Sahyoun N, Serdula M, Galuska D, Zhange X, Pamuk E. The epidemiology of recent involuntary weight loss in the United States population. J Nutr Health Aging. 2004;8:510-517.[Medline]
- Fey-Yensan N, English C, Pacheco H, et al. Elderly food stamp participants are different from eligible nonparticipants by level of nutrition risk but no nutrient intake. J Am Diet Assoc. 2003;103:103-107.[Medline]
- Marshall T, Stumbo P, Warren J, et al. Inadequate nutrient intakes are common and are associated with low diet variety in rural, community-dwelling elderly. J Nutr. 2001;131:2192-2196.[Abstract/Free Full Text]
- McKie L, MacInnes A, Hendry J, et al. The food consumption patterns and perceptions of dietary advice of older people. J Hum Nutr Diet. 2000;13:173-183.[Medline]
- Callen B, Wells T. Views of community-dwelling old-old people on barriers and aids to nutritional health. J Nurs Scholarsh. 2003;35:257-262.[Medline]
- Lucas J, Orshan S, Cook F. Determinants of health-promoting behavior among women ages 65 and above living in the community. Sch Inq Nurs Pract. 2000;14:77-100.[Medline]
- Patterson R, Kristal A, Coates R, et al. Low-fat diet practices of older women: prevalence and implications for dietary assessment. J Am Diet Assoc. 1996;96:670-679.[Medline]
- Clarke L. Older women's perceptions of ideal body weights: the tension between health and appearance motivations for weight loss. Aging Soc. 2002;22:751-773.
- Marshall J, Lopez T, Shetterly S, et al. Indicators of nutritional risk in the rural elderly Hispanic and non-Hispanic white population: San Luis Valley health and aging study. J Am Diet Assoc. 1999;99:315-322.[Medline]
- Miller D, Carter M, Sigmund R, et al. Nutritional risk and inner-city-dwelling older Black Americans. J Am Geriatr Soc. 1996;44:960-962.
- Coulston A, Craig L, Voss A. Meals-on-Wheels applicants are a population at risk for poor nutritional status. J Am Diet Assoc. 1996;96:570-573.[Medline]
- Jensen G, Kita K, Fish J, et al. Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges. Am J Clin Nutr. 1997;66:819-828.[Abstract/Free Full Text]
- Payette H, Coulombe C, Boutier V, et al. Nutrition risk factors for institutionalization in a free-living functionally dependent elderly population. J Clin Epidemiol. 2000;53:579-587.[Medline]
- Keller H, Ostbye T, Goy R. Nutritional risk predicts quality of life in elderly community-dwelling Canadians. J Gerontol A Biol Sci Med Sci. 2004;59A:68-74.
- Green P, Adderley-Kelly B. Health promotion for urban elderly: a survey of learning needs. J Natl Black Nurses Assoc. 2002;13:38-44.[Medline]
- Lee J, Kritchevsky S, Tylavsky F, et al. Weight change, weight change information, and the incidence of mobility limitation in well-functioning community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2005;60:1007-1012.[Abstract/Free Full Text]
- Lee J, Kritchevsky S, Tylavsky F, et al. Weight-loss intention in the well-functioning, community-dwelling elderly: associations with diet quality, physical activity, and weight change. Am J Clin Nutr. 2004;80:466-474.[Abstract/Free Full Text]
- Lee J, Kritchevsky S, Harris T, Tylavsky F, Rubin M, Newman A. Short-term weight changes in community-dwelling older adults: the health aging and body composition weight change substudy. Am J Clin Nutr. 2005;82:644-650.[Abstract/Free Full Text]
- Newman A, Lee J, Visser M, et al. Weight change and the conservation of lean mass in old age: the Health Aging and Body Composition Study. Am J Clin Nutr. 2005;82:872-878.[Abstract/Free Full Text]
- Sahyoun N, Zhang X. Dietary quality and social contact among a nationally representative sample of the older adult population in the United States. J Nutr Health Aging. 2005;9:177-183.[Medline]
- de Groot L, van Staveren W. Undernutrition in the European SENECA studies. Clin Geriatr Med. 2002;18:699-708.[Medline]
- de Groot L, Verheijden M, de Henauw S, Van Staveren W. Lifesyle, nutritional status, health and mortality in elderly people across Europe: a review of the longitudinal results of the SENECA study. J Gerontol A Biol Sci Med Sci. 2004;50A:1277-1284.
- Streubert H, Carpenter D. Qualitative Research in Nursing: Advancing the Humanistic Imperative. 2nd Ed. Philadelphia, PA: Lippincott; 1999.
- de Groot L, Beck A, Schroll M, et al. Evaluating the DETERMINE Your Nutritional Health Checklist and the Mini Nutritional Assessment as tools to identify nutritional problems in elderly Europeans. Eur J Clin Nutr. 1998;52:877-883.[Medline]
- Reuben D, Greendale G, Harrison G. Nutrition screening in older person. J Am Geriatr Soc. 1995;43:415-425.[Medline]
- Drewnowski A, Evans W. Nutrition, physical activity, and quality of life in older adults: summary. J Gerontol A Biol Sci Med Sci. 2001;56:89-94.[Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
C. S. Ritchie, J. L. Locher, D. L. Roth, T. McVie, P. Sawyer, and R. Allman
Unintentional Weight Loss Predicts Decline in Activities of Daily Living Function and Life-Space Mobility Over 4 Years Among Community-Dwelling Older Adults
J. Gerontol. A Biol. Sci. Med. Sci.,
January 1, 2008;
63(1):
67 - 75.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
National Health and Nutrition...
Survey in Europe on...
