© Borgis - New Medicine 1/2008, s. 20-24
*Joanna Wyka, Jadwiga Biernat
NUTRITIONAL KNOWLEDGE AND EATING HABITS OF ELDERLY WOMEN FROM BIG-CITY ENVIRONMENT
Chair of Human Nutrition Department of Agricultural Technology and Storage Wrocław University of Environmental and Life Sciences Head of Chair: Jadwiga Biernat, MD, PhD
Aim: The study was undertaken to evaluate nutritional knowledge and eating habits of women over 60 years of age from the big-city environment.
Material and methods: Nutritional knowledge and eating habits of 234 senior women over 60 years of age from Wrocław were evaluated by means of a direct interview and based on a validated questionnaire elaborated at the Chair of Human Nutrition.
Results: Ca. 91% of the examined senior women claimed that diet exerted a significant effect on human health. Amongst food products recommended for frequent consumption the women included fruits and vegetables (93% of answers), white meat (78% of answers) and dairy products (70%), whereas amongst those from the group – „I consume rarely” the included: red meat (75%) and sweets (74%). The proper number of glasses of beverages drunk daily (i.e.8-9) was indicated by as little as 23% of the subjects. Usually, the women were eating 3 meals a day (47%) and did not salt them additionally on the plate (70%). Ca. 60% of the seniors were using dietary supplements every day (usually of two types). The qualitative assessment of nutrition patterns demonstrated that everyday consumption of milk was declared by 45% of the women, that of fruits – by 75% of the women, that of vegetables – by 80% of the women, and that of non-carbonated mineral water – by 60% of the seniors. Ca. 63% of the women examined evaluated their eating habits as satisfactory. Most of the respondents (85%), however, pointed to the need of nutritional education, dietetic in particular, amongst the elderly.
Conclusion: The level of nutritional knowledge was good in most of the women examined, which has been indicated by answers collected in the survey. In order to improve health status, however, additional intensified health-promoting actions are necessary in the entire population of the elderly people.
Problems of body ageing and also these of nutrition patterns of the elderly are a subject of sample contempo-rary research. This has been affected, to a substantial extent, by the elongation of the average life span of humans observed in recent years. In the year 2000, the number of people over 60 years of age world-wide reached 0.8 mld and is estimated to increase to 1.8 mld in the year 2030 [26,27]. In Poland, in the year 2004 the percentage of people over 60 years of age reached 17% and is forecast to increase to 24%, namely ca. 9.1 millions, in the year 2030 . Likewise in other European countries, the demographic situation of Poland requires undertaking actions aimed at improving living standards in the basic spheres of social life in that age group [10,24].
The proper nutrition patterns of people in advanced age are one of the factors affecting, to a significant extent, both their nutritional and health status. They determine the apt functioning of the body as well as are likely to contribute to delayed occurrence of symptoms of the ageing process [20,21]. The elderly people, with their preferences and diseases recovered, often necessitate additional, intensified dietary intervention. There is a number of factors that affect the nutrition patterns of humans, including: educational status, mode of live and work, bearing stress, financial status as well as nutritional knowledge and eating habits. Comprehension of the effect of those factors is significant due to both the possibility of assessing the risk of diet-dependent diseases and their prevention. Some behavioral factors, i.a. tobacco smoking, alcohol abuse, incorrect eating habits and low physical activity, may be subject to modifications through an apt change of lifestyle [6, 19].
An overview of domestic and international literature points to a number of irregularities linked with the process of nutrition observed amongst the elderly [2,4,9,18]. Most of people of that age group have insufficient nutritional knowledge and make numerous mistakes in their eating habits, which is in turn reflected in their health status .
A study was undertaken, therefore, to evaluate nutritional knowledge and eating habits of women over 60 years of age living in the city of Wrocław.
Material and methods
In March and April of 2007, a survey was conducted in three Seniors Clubs and one selected clinic to evaluate the nutritional knowledge and eating habits of 234 elderly women from the city of Wrocław.
Eating habits were evaluated by means of the direct interview method. The interview questionnaire consisted of three parts. The first one referred to socio-demographic data and lifestyle, it additionally comprised ten questions linked, among others, with: personal data, economic status, evaluation of physical activity, potential problems encountered by the respondents in everyday life, and possibilities of spending free time. The second part of the questionnaire entitled "Nutritional knowledge and eating habits” included eighteen detailed questions about, i.a.: level of the nutritional knowledge of the respondents, frequency of consumption of particular meals within a day, type of diet applied, the use of table salt and sugar as well as the application of commercially-available dietary supplements. The third part of the questionnaire – „Nutrition history” comprised questions referring to consumption frequency of selected food products as well as nutritional preferences and likings of the respondents. Data on the customary nutritional patterns were obtained based on answers to 62 questions.
Validation of a self-constructed questionnaire
Reliability and repeatability of results obtained with the use of the self-constructed questionnaire were evaluated with the validation method. The suitability of a given method was evaluated by determining correlation coefficients as well as indices of sensitivity and specificity . A statistical analysis of results was conducted with the use of "Statistica 8” software, a chi2 test and Spearman´s correlation.
In the evaluation of the reliability of the questionnaire used in the study there participated 27 women who filled in the same questionnaire twice in a two-week interval. Individual variability, indicating the repeatability of answers obtained for the same respondents in the first and second questionnaire, was verified by determining coefficients of Spearman correlation ®. In turn, inter-individual variability was evaluated with the use of the chi2 test (at a significance level of p=0.05), by comparing mean frequencies of the traits examined for the entire group in the first and second interview.
A comparison of the results obtained in the first and second questionnaire survey did not demonstrate any significant differences in the answers provided. The percentage of answers consistent in both questionnaires reached 96.2%. The obtained high coefficient of Spearman correlation (r=0.77) pointed to a low intra-individual variability and to a good repeatability of the results achieved. Due to diversity of questions included in the questionnaire, the consistency of answers and correlation coefficients were determined separately in the three parts of the questionnaire. In the part referring to the socio-demographic data and lifestyle the percentage of consistent answers accounted for 98.7% and the Spearman correlation coefficients varied between r=0.47 and r=0.93. In the second part of the questionnaire referring to the nutritional knowledge and eating habits the correlation coefficients ranged from r=0.41 to r=0.93. In turn, the consistency of answers in that part of the questionnaire accounted for 95.9% and in the last part referring to the history of nutrition – for 95.8%.
A lack of differences (statistically insignificant p value) determined with the chi2 test and high coefficients of Spearman correlations obtained for both the questionnaires indicated low intra-individual as well as inter-individual variability. It enables classifying the self-constructed questionnaire used in the evaluations of the nutritional patterns of the elderly as a suitable tool for both individual and collective assessment.
Lifestyle of women under study
In the study, the highest percentage of women were at the age of 60-75 years (64% of the subjects), next those at the age of 76-85 years (32% of the subjects), and 4% of the subjects were over 86 years of age. Amongst the women surveyed, 21% had primary education, 14% – vocational education, 44% – secondary education, and 21% – higher education. In majority of respondents (88% of the subjects) the main source of income was retirement pension, for 10% of the subjects – state pension, and for 2% of the women – salary. Ca. 34% of the women declared their monthly income in the range of 701-1000 PLN, and 14% – in the range of 501-700 PLN, whereas 52% of the respondents declared their earned incomes to exceed 1000 PLN. Ca. 45% of the elderly women examined declared that they lived with their closest family (i.e.: with wife/husband/children or grandchildren), whereas the other women lived alone without the help of other persons (38%) or alone but with the help of other persons (9% of the subjects).
Amongst the women surveyed, the most often form of leisure activity was the so-called "passive rest”. In the questionnaire, the women could choose 3 out of 7 possible answers; most often they chose reading newspapers and books (63%) as well as watching TV (51%). Half the women evaluated the level of their physical activity as average, 36% as active, and 15% as non-active. Most of the respondents (72%) did not encounter any problems while doing shopping. In the other group of the elderly women the greatest difficulties included: carrying a shopping basket, climbing stairs and reading out the price specified on a product.
Nutritional knowledge and eating habits
Most of the respondents claimed that the level of their nutritional knowledge was good (63%), or sufficient (25%). Worthy of notice is the fact that none of the elderly women surveyed evaluated their nutritional knowledge as bad, whereas 12% of the women declared to have very good knowledge of nutrition. Once asked about the source of information on nutrition (3 answers could be chosen) the women declared: own experience (63%), the press (53%), and TV programmes (34%). To a small group of women (ca. 10%), the source of nutritional knowledge were either nutritional courses or workshops or labels of food products.
In the survey, the respondents were also asked about their opinion on the necessity of introducing programmes of nutritional educations amongst seniors. Ca. 85% of the women found the nutritional education for the elderly necessary since nutrition has a significant impact on health (91% of positive answers). A lack of any relationship between nutritional patterns and health status or "I do not know” answer were confirmed in 3% and 6% of the respondents, respectively.
The application of diet was declared by 43% of the seniors. It usually resulted from the necessity of adjusting their diets to disease entities they suffered from. A therapeutic diet used most often by the women surveyed was: a diet applied in arterial hypertension (21 of the seniors) or in diabetes (26 of the seniors) as well as an easily digestible diet (34 of the seniors).
The women were also asked to answer a question about the use of dietary supplements. The answers collected demonstrated that dietary supplements were applied by 43% of the women. The reasons of taking the supplements were mainly their benefits emphasized in TV advertisements or in a pharmacy (31% and 20% of answers, respectively), whereas dietary supplements prescribed by a physician were taken by 25% of the women. Most of the respondents (61%) declared taking vitamin preparations (including vitamin C, B complex, vitamin B12). The second preferred type of dietary supplements were complexes of vitamins (i.e. Centrum, Biovital), applied by 38.3% of the women.
Once asked about food products that should be consumed most frequently (3 answers were possible), 93% of the respondents pointed to fruits and vegetables, 78% to white meat, 70% to dairy products. In contrast 6% of the women indicated red meat and 2% of the seniors – fats of animal origin and sweets. Amongst food products that should be consumed rarely, the respondents included: animal fats (89%), sweets (74%), and red meat (75%). Ca. 23% of the women surveyed declared the proper daily intake of fluids (8-9 glasses), whereas 38% of the respondents declared to drink 4-5 glasses of fluids a day. Around 16% of the women were shown to consume 5 meals a day, which is consistent with recommendations for rational nutrition of that age group. Distinct majority of the respondents (47%) declared having three meals a day, whereas 4% of the women surveyed to have 1-2 meals a day. Most of the surveyed women consumed the I breakfast (97.6% of all respondents), dinner (96.4%) and supper (83.3%) every day.
Qualitative assessment of eating habits
In the part of the questionnaire referring to the history of nutrition, assessments were conduced for the frequency of consumption of selected food products. Almost half the women surveyed declared everyday consumption of white bread and wheat rolls, which is an undesirable habit according to nutritional recommendations for that group of food products. As little as 32% of the women consumed dark bread 2-3 times a week, whereas everyday consumption of that type of bread was declared by only 28% of the women. Carbohydrate products (of muesli type, bran, breakfast cereals) were not consumed by ca. 40% of the respondents at all. In turn, everyday consumption of that type of products was declared by as little as 15% of the seniors. When it comes to pasta as well as groats and rice, respectively 80% and 32% of the women declared to eat them once a week.
Ca. 45% of the respondents declared to eat butter every day. In turn, everyday consumption of butter-margarine type spreads (a mix of spreads) was demonstrated amongst 25% of the women. It was also shown that soft margarines were not consumed at all by 60% of the seniors, whereas hard margarines – by ca. 74% of all the women examined. Worthy of notice is the fact that a considerable group of the women (75%) did not consume lard, which is consistent with proper nutrition guidelines.
Based on answers to questions about the frequency and type of meat consumed it was demonstrated that poultry meat was consumed every day by 6% of the women, and 2-3 times a week by 42% of the respondents. It was also shown that 32% of the women consumed pork meat 2-3 times a week. The consumption of beef less than once a week was demonstrated in 37% of the respondents. Attention should be paid to the fact that over half the women surveyed did not consume bacon nor headcheese. Similar behaviors were observed in the case of offals that were not consumed by 65% of the women surveyed in the study. In the examined group of seniors, the consumption of frankfurter type sausage and liver pastry two or three times a week was demonstrated in 24% of the women. A considerable percentage of the respondents (41%) did not consume that type of products at all. In the case of processed meat products, the surveyed women consumed poultry products much more frequently than the pork ones. Everyday consumption of poultry cured meat was demonstrated in 35% of the women, whereas that of pork cured meat in 10% of the respondents. The highest percentage of the women (52%) declared to consume fish once a week. All the seniors surveyed were also asked about consumption frequency of four types of cheeses (i.e. cheese spread, blue-veined cheese, fresh white cheese and hard cheese). Everyday consumption of hard cheeses was demonstrated in a group of 17% of the women, that of fresh white cheeses in 13% of the seniors, and that of cheese spread in 11% of the respondents. The highest percentage of the respondents (45%) declared to consume fresh white cheeses 2-3 times a week. The intake of hard cheeses with the same frequency (i.e. 2-3 times a week) was demonstrated in a group of over 25% of the women examined. Blue-veined cheeses and cheese spreads were usually (ca. 50% of the women) not consumed at all. Dairy products inquired in the questionnaire included also yoghurts and kefirs, the everyday consumption of which was demonstrated in a group of 28% of the women, whereas their intake 2-3 times a week – in 33% of the senior. Everyday drinking of milk was declared by 45% of the women under study.
Everyday consumption of potatoes was demonstrated in 25% of the seniors, whereas that of fruits and vegetables – in 75% and 80% of the women, respectively. Answers to questions about consumption frequency of jam and honey showed that 13% of the women consumed those products every day. In a group of 25% of the seniors, the intake of jam and honey was declared 2-3 times a week, whereas in 28% of the women – less than once a week. Ca. 30% of the women consumed sweets 2-3 times a week. Everyday consumption of sweets was observed in a group of 18% of the women, which is likely to constitute the direct cause of the development of obesity or/and insulin resistance. A considerable part of the women (60%) were shown to drink coffee every day, whereas 54% of the respondents declared not to drink sweet carbonated drinks. Everyday intake of non-carbonated mineral water was reported in 60% of the seniors. Most of the women (85%) were demonstrated to drink tea every day.
The level of nutritional knowledge of the surveyed elderly women from Wrocław was evaluated based on answers from a questionnaire that had previously been subjected to a validation procedure. Most of the examined seniors were aware of a significant impact of eating habits on their health status (91%). A study by Kołłajtis-Dołowy et al. , aimed at evaluating the nutritional awareness in a group of 143 elderly persons, demonstrated that almost half the subjects (49% of all the examined persons) admitted that the nutritional patterns exerted a significant effect on the health status. The seniors from Wrocław drew their nutritional knowledge mainly from their own experiences and relevant articles in the press and TV programmes. The study by Kołłajtis-Dołowy et al.  demonstrated a positive influence of educational activities in a series of radio programmes on the increase of nutritional awareness.
Most of the women examined in the reported survey did not suffer any problems while doing shoping. In contrast, such problems were declared by 65% of the elderly subjects inquired in a research by Niedźwiedzka et al. ; the problems involved difficulties in walking up and down the stairs and opening doors (15% of the respondents), covering the distance to a shop and carrying the groceries back home (12 % of the respondents). Almost half the elderly women from Wrocław declared to eat 3 meals a day, including I breakfast, dinner and supper. This was consistent with a study by Chwojnowska et al. , conducted in a group of 86 elderly women and 70 men, who demonstrated that over 50% of the examined subjects consumed 3 meals a day and that 11% of the men and 8% of the women consumed two meals a day. Having at least 4 meals a day was demonstrated in 41% of the women. Results of investigations by Szewczyński et al. [22,23], conducted in a group of senior women (n=223), demonstrated that the I breakfast was consumed by 95.1%, dinner by 98.7% and supper by 86.6% of the women under study. In turn, the evaluation of eating habits of 50-year-olds from Wrocław carried out by Ilow et al.  showed that in the examined group (women n= 502) most frequently eaten meal was the I breakfast and dinner (79%).
Half the surveyed senior women from Wrocław were shown to use dietary supplements. Corresponding results were obtained by Kałuża et al. [7,8] in a group of 206 elderly people, i.e. 42.2% of the respondents declared to take vitamins and minerals originating from dietary supplements. Amongst those taking such preparations, 59% were applying vitamin-mineral complexes, 16% were using supplementation with two or more vitamins, and 15% were taking supplements containing mineral compounds. A study by Marshall et al. , carried out in a group of 261 elderly inhabitants of the Iowa State in the USA, demonstrated that 20% of the respondents were using dietary supplements. According to Ilow et al. , regular supplementation with vitamins and minerals was observed in 14.7% of 50-year-old female inhabitants of Wrocław.
Everyday consumption of milk was demonstrated in 45% of the elderly women from Wrocław. In turn, a research by Myszkowska-Ryciak et al. , conducted on a group of 29 women from the University of Third Age in Warsaw, demonstrated that 30% of the respondents consumed milk and dairy products at least once a day. In the study of Ilow et al. , a higher percentage of 50-year-old women than men at the same age drank 0.5 to 2 glasses of milk a day (51.2% vs. 36.8%). In the cited study, ca. 47% of the women declared a lack or irregular intake of kefir and yoghurt. In addition, the highest percentage of the respondents did not pay attention to fat level in yoghurts (29.7% and 36.2%, respectively). Investigations conducted by Duda  in a group of 302 elderly inhabitants of Poznań showed that over 47% of the respondents used butter to spread bread. In the group of the elderly women from Wrocław, everyday consumption of butter was demonstrated in ca. 45%, whereas a lack of consumption of soft margarines – in ca. 60% of the respondents.
1. The elderly women from Wrocław were characterized by good nutritional knowledge, which was indicated by their answers to questions on the selection of food products that should be consumed most frequently and rarely. Nevertheless, it was not their knowledge but their own experience (not always correct) that determined the proper selection of food products by the women.
2. The qualitative assessment demonstrated numerous nutritional inaccuracies in a considerable number of the senior respondents, i.e: low intake of milk and dairy products, vegetables and fruits, fluids as well as wholemeal cereal products.
3. Incorrect eating habits and passive lifestyle of the women surveyed point to the necessity of intensifying educational activities in the examined group of elderly women.
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