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ABSTRACT

NUTRITIONAL STATUS OF OLDER WOMEN

BY

Eleanor Dawn Schlenker

In recent years, medical advances in the conquest
of infectious diseases have increased the lifespan
markedly. Many factors determine the health and longevity
of older people. Proper nutrition throughout life has
been suggested as one of the best means of minimizing
degenerative changes and superimposed diseases. To studY
the influence of nutritional status in middle age upon
kmalU1in.later years, ultimate longevity, and cause Of
death, the survivors of a random sample of 103 women from
Lansing, Michigan, first studied in 1948 when they ranged
in age from 40 to 88 years, were re-examined. In 1948:
emfllsubject was interviewed to obtain a 24-hour dietary
recall record, and health and nutrition history? about one-
half of the subjects submitted to a clinical evaluation
Whnfllincluded the collection of fasting blood samples for

Vitamin analyses .

Sixty of the original subjects are deceased.

TWflWY‘Eight survivors, ranging in age from 64 to 90 years,

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gmrtuflrmted in the 1972 study. From these individuals was
obtained at least one 24-hour dietary record and information
relating to current socioeconomic, marital, and health
status. Twenty women submitted to a clinical examination
with emphasis upon signs of nutrient deficiency. Bio-
chemical measurements to evaluate iron, protein, and

vitamin status, were performed on fasting blood and urine
samples. A modified test of glucose tolerance was con-
ducted using a high carbohydrate breakfast consisting of
50-60 grams carbohydrate.

According to the death certificates obtained for
the deceased subjects, cardiovascular—renal disease was
responsible for nearly one-half of all deaths, with cere-
brovascular complications and cancer, the next leading
causes of death. No single nutrient in the 1948 diets
could be related to cause of death. The intake of dietary
fat, on an absolute basis, however, was inversely corre-
lated with age at death. The higher the intake of fat, the
Shorter the life. Similarly, the higher the level of
carbohydrate as percent of total calories, and the lower
the Percent of fat calories, the longer the life. Survivors,
when examined in 1948, had significantly higher intakes 0f
dietary Protein and ascorbic acid than those DOW deceased;
the survivors were also significantly younger in age at the
time of the initial survey.

For the 28 women examined in 1972, mean caloric

intake was about two-thirds (1297 kcal) that recommended

 

 

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for women of this age, although mean intakes of other
nutrients, except calcium, remained adequate. Deficient
intakes by individuals most frequently involved calories,
calcium, thiamin, and vitamin A. Nearly one-half of those
interviewed used some form of dietary supplement, although,
in most cases, the supplement taken did not supply those
nutrients that were deficient in the diet. Socioeconomic
factors as economic limitations or problems with shopping,
or dental status, did not significantly affect nutrient
intake. Women who lived and ate alone, however, had

lowered intakes of calories, fat, protein, iron, and niacin;
however, these subjects also tended to be older. Women
following modified diets for treatment of chronic diseases,
had reduced intakes of fat, linoleic acid, and ascorbic
acid.

Comparison of the nutrient intakes of the survivors
in 1948 and 1972 revealed that dietary intakes of calories,
carbohydrate, and fat, decreased significantly, whereas
Protein levels remained the same. Since the 1948 survey,
survivors have increased their use of eggs and vitamin-A
rich fruits and vegetables, continued to consume bread and
cereals frequently, and decreased their intakes of high-
sucrose baked desserts. Since 1948, vegetable fats have
been subStituted for animal fats in the diet.

Clinical symptoms frequently associated with
nutrier“: deficiencies, were, in these subjects, not alwaYS

rent-Ed to nutrient intake. Oral lesions as angular

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stomatitis or filliform papillae atrophy, were associated
with dentures rather than a deficiency of the B complex
\dtamins or iron. Hyperkeratosis of the elbows and knees
dnirelate to lowered intake of linoleic acid. Neurologic
cmanges were associated with advancing age rather than
nubfitional status. Spinal curvature was significantly
related to body weight in 1948. Similarly, the presence
ofheart disease in 1972 was associated with overweight and
hypertension in 1948. 'About one-half of the subjects had
mikiedema of the lower extremities and/or varicose veins.

Biochemical values observed in these women were
acceptable to high in the majority of subjects. Serum
\fitamin.A and carotene levels were not correlated with
<hetary intake, although two subjects who had undergone
cmolecystectomies had serum vitamin A levels indicative of
ckfiiciency. Urinary riboflavin was low in 15 percent of
13m subjects, although biochemical measures of ascorbic
acid, thiamin, and iron status, were adequate in all women
examined. Decreased levels of serum protein, noted in one-
fluid of the subjects, reflected changes in the globulin
rather than the albumin fraction.

Body height was significantly lower among the oldest
SulDjects examined. Body weight, skinfold thicknesses, and
bodyCircumferences, were decreased in the subjects aged 80
orabove- More than one-half of the women examined were

20“340 percent overweight, and had been so in 1948; only

15pmmcent were severely underweight. Arm and abdominal

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circumferences were the single measurements most highly

correlated with body weight. Post-prandial glucose and

insulin levels were significantly related to body weight as

recorded in 1948.

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NUTRITIONAL STATUS OF OLDER WOMEN

BY

Eleanor Dawn Schlenker

A DISSERTATION

Submitted to
. Michigan State University
In partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
DePartlment of Food Science and Human Nutrition

1976

Copyright by
© ELEANOR DAWN SCHLENKER

1976

Life must be lived forward, but

understood backward.

Soren Aabye Kierkegaard

To the twenty-eight women who
shared with us their food

habits and way of life.

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ACKNOWLEDGMENTS

I wish to express my deepest appreciation to my
advisor, Dr. Olaf Mickelsen, for his guidance, patience,
and insight, throughout my graduate program; to my committee
maflmrs, Dr. D. C. Cederquist, Dr. H. D. Hafs, and
Dr. W. D. Van Huss, for their advice and help throughout
this research; to Dr. J. L. Gill, for. suggestions regarding
statistical procedures; and to Dr. M. J. Yang, formerly of
Michigan State University, for help with analytic procedures.
I would also like to acknowledge the enthusiastic support
given to this study by the late Dr. J. S. Feurig, who served
as a member of the guidance committee and performed the
clinical evaluations of the study subjects. I could not
have proceeded without the help of Dr. M. A. Ohlson, the
Principal investigator of the initial survey, who spent
many hours with me, organizing and evaluating the 1948
records.

This project would not have been possible without
the Concerned cooperation of many staff members at Olin
Health Center, Michigan State University, including:

MS' 3- 3- Kreuger, Dietitian, and her staff; Ms. J. E.

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Milan, Director of Nursing and Ms. M. DeWitt, Head Nurse,

and their staff; Ms. M. L. Shick, Chief Technologist, and

her staff; and Ms. N. L. Tomanica, Chief X-ray Technologist,
and her staff.

Special thanks are expressed to Dr. L. H. Stone,
Lansing, Michigan, who performed the dental examinations,
and Dr. D. R. Romsos and Ms. K. L. Muiruri, Department of
Food Science and Human Nutrition, Michigan State University,
who performed the urinary riboflavin analyses.

I am very grateful for the financial support
afforded to me and this research study by the Alumnae
Association of the School of Human Ecology, Department of
Food Science and Human Nutrition, School of Human Ecology,
and Womens' Faculty Association, of Michigan State Uni-
versity; General Foods Corporation; McGregor Fund of
Detroit, Michigan; and the National Institutes of Health,
Public Health Service, Grants GMO-1313 and HD06739-01; all
Of whom helped to make this program possible.

Finally, I wish to acknowledge the constant support
and encouragement of my father, from whom I have learned to

Value the opportunity to study.

iv

TABLE OF CONTENTS

Page

LIST OF TABLES . . . . . . . . . . . . . x

LIST OF FIGURES. o o o o o o o o o o o o XV

INTRODUCT ION O O O O O O O O O O O O O O 1
Chapter

I. REVIEW OF LITERATURE. . . . . . . . . 5

Trends in Longevity and Mortality. . . . 5

Life Expectancy . . . . . . . . . 5

Causes of Death . . . . . . . . . 6

Factors Affecting Mortalit . . . . . 8

Nutrition and Longevity . . . . . . . 14

Historical PerSpective. . . . . . . 14

Human Nutrition Studies . . . . . . 15

Animal Studies . . . . . . . . . 26

Nutrient Requirements of Older People . . 36

Factors Affecting Requirements . . . . 37

Absorption Mechanisms . . . . . . . 38

Calorie and Energy Needs . . . . . . 42

Energy Expenditure . . . . . . . . 44

Basal Metabolic Rate . . . . . . . 45

Thyroid Function. . . . . . . . . 46

Body Composition. . . . . . . . . 47

Protein Requirements . . . . . . . 50

Amino Acid Requirements . . . . . . 53

Effect of Anabolic Steroids . . . . . 56

Plasma Proteins . . . . . . . . . 56

Vitamin Requirements . . . . . . . 58

Water-soluble Vitamins. . . . . . . 58

Fat-soluble Vitamins . . . . . . . 67

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Minerals . . . . . . . . . . . 70
Bone Mineral Loss . . . . . . . . 71

Factors Influencing Food Choices of

Older People. . . . . . . . . . 80
Age. 0 I O O O O O O 0 O 0 O 81
Physical Aspects . . . . . . . 82
Social- -Psychological Aspects . . . . 86

II. INFLUENCE OF PHYSIOLOGIC, SOCIOLOGIC AND
ECONOMIC FACTORS UPON NUTRIENT INTAKE OF

OLDER WOWN O O O O I O O O I O O 9 1
Introduction . . . . . . . . . . 91
MethOds O I C O O O O O O O O O 9 2
Original Study . . . . . . . . . 92
Present Study . . . . . . . . . 94
Results . . . . . . . . . . . . 96
Nutrient Intakes From Food . . . . . 96
Nutrient Intakes and the RDA . . . . 98
Dietary Supplements . . . . . . . 100
Age and Nutrient Intake . . . . . . 104
Meal Pattern and Nutrient Intake . . . 104
Meal Planning . . . . . . . . . 108
Shopping Problems . . . . . . . 109
Social Activity and Nutrient Intake . . 110
Food Avoidance and Nutrient Intake . . 111
Prescribed Diets and Nutrient Intake. . 114
Physical Activity and Nutrient Intake . 114
Loss of Appetite . . . . . . . . 115
Discussion . . . . . . . . . . . 115
Problems in Assessing Nutrient Intake
in Older Women . . . . . . . . 115
Nutrient Intake in Older Women. . . . 120
Socioeconomic Patterns and Nutrition
in Older Women . . . 125
Physiologic Aspects of Food Habits in
Older Women . . . . . . . . . 129
Conclusions. . . . . . . . . . . 131

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III. NUTRIENT INTAKE IN 1948 AND SUBSEQUENT

MORBIDITY AND MORTALITY . . . . . . . 133
Introduction. . . . . . . . . . . 133
Methods . . . . . . . . . . . . 135
Resu1ts O O O O O O O O O O O O 136

Nutrient Intakes of Deceased and Survivors

in 1948 . . . . . . . . . . . 136
Biochemical Indices of Deceased and

Survivors in 1948. . . . . . . . 141
Nutrient Intake and Age at Death . . . 141
Blood Pressure and Age at Death. . . . 150
Nutrient Intake and Cause of Death. . . 150

Nutrient Intake and Chronic Disease
Contributing to Death . . . . . . 155

Nutrient Intake and Physical Symptoms. . 160
Discussion . . . . . . . . . . . 166
Nutrient Intake and Longevity . . . . 166
Possible Mechanism of Action of Dietary
Fats O O O O O I O O O O O O 172
Mortality and Cause of Death. . . . . 176
Body Weight and Blood Pressure . . . . 180
Conclusions . . . . . . . . . . . 182
IV. CHANGES IN FOOD INTAKE OF DECEASED AND
SURVIVORS BETWEEN 1948 AND 1972 . . . . 184
Introduction. . . . . . . . . . . 184
Methods . . . . . . . . . . . . 185
Results . . . . . . . . . . . . 186

Differences in Nutrient Intake Between

1948 and 1972 . . . . . . . . . 191
Differences in Food Choice Between

1948 and 1972 . . . . . . . . . 193

Discussion . . . . . . . . . . . 212

Food Selection as Related to Food

Availability . . . . . . . . . 220
Conclusions . . . . . . . . . . . 230
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V. INFLUENCE OF NUTRIENT INTAKE UPON CLINICAL

AND BIOCHEMICAL PARAMETERS IN OLDER WOMEN . 231
Introduction. . . . . . . . . . . 231
Methods . . . . . . . . . . . . 232
Results . . . . . . . . . . . . 238
Incidence of Clinical Abnormalities . . 238
Dental Characteristics and Food
Restrictions . . . . . . . . 246
Biochemical Indices of Nutritional
Status . . . . . . . . . . . 247
Vitamin Status . . . . . . . . . 252

Relation Between Clinical Symptoms,
Nutrient Intake, Physical Factors,
and Age . . . . . . . . . . . 258
DiSCllSSion ' o o o o o o o o o o o 279

Problems in Assessing Nutritional Status

in Older Pe0ple . . . . . . 279
Clinical Aspects of Nutrition and Aging . 280
Cardiovascular Function and Blood

Pressure in Older Women. . . . . 287
Dental Status and Nutrient Intake . . . 291
Biochemical Measures of Nutritional

Status in Older Women . . . . . . 293

Conclusions . . . . . . . . . . . 307

VI. PHYSICAL MEASUREMENTS AND GLUCOSE TOLERANCE

IN OLDER WOWN O I O O O I O O O O 309
Introduction. . . . . . . . . . . 309
Methods of Procedure . . . . . . . . 310
Results 0 O O I O O O O O 0 O 0 312

Anthropometric Measurements . . . . 312

Relationships Between AnthrOpometric

Measurements and Body Weight . . . . 321
Basal Metabolic Rate . . . . . . . 321
Glucose Tolerance . . . . . . . . 325
Serum Cholesterol Levels . . . . . . 333

DiSCL‘lSSion o o o o o o o o o o o 335
Changes in Physical Measurements With

Age 0 o o o o o o o o o o o 335
problems in Assessing Body Fatness in

01 der People 0 o o o o o O o o 3 3 9

viii

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Changes in Body Weight in Older People . 342
Problems in Estimating Energy Balance
in Older People . . . . . . . . 345
Evaluation of Glucose Tolerance in
Older PeOple . . . . . . . . . 348
Serum Cholesterol Levels in Older
People 0 O C O O I I O O 0 O 3 5 6
Conclusions. . . . . . . . . . . 358
BIBLIOGRAPHY O O O 0 O O O O O O O O O 3 6 O
APPENDICES
Appendix
A. Instruments and Supplementary Data for
Chapter II . . . . . . . . . . . 392
B. Instruments and Supplementary Data for
Chapter III. . . . . . . . . . . 408
C. Supplementary Data for Chapter IV . . . . 412

D. Instruments and Supplementary Data for
Chapter v C O O O I O O O O O O 4 l S

E. Instruments and Supplementary Data for
Chapter VI . . . . . . . . . . . 439

ix

 

 

 

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Table

II-l.

II-4.

II-S.

II-6.

II-9.

II-lO.

III-1.

III-2.

LIST OF TABLES

Page

Living Arrangements of Older Women Examined

in 1972 O O I O O O I O O C O O 96
Mean Nutrient Intakes of Older Women

Examined in 1972 . . . . . . . . . 97
Percentage of Subjects Whose Nutrient

Intakes in 1972 Were Equal to, or a

Fraction of, the RDA. . . . . . . . 99
Dietary Supplements Used by Older Women

Examined in 1972 . . . . . . . . . 101
Mean Nutrient Intakes of Older Women

Examined in 1972 According to Age . . . 105
Meal Patterns of Older Women Examined in

1972 O O O O O O O O O O O O O 106
Relation of Meal Pattern, Nutrient Intake

and Age Among Older Women Examined in

1972 O O I O O O O I I O I O 0 107
Factors Considered in Meal Planning by

Older Women Examined in 1972 . . . . . 109
Foods Avoided by Older Women Examined in

1972 O O C I C O O O O I O O O 11.2
Relation of Physiologic Factors, Nutrient

Intake and Age Among Older Women Examined

in 1972 O O O O O O O O O O O O 113
Comparison of Nutrient Intakes of Subjects

in 1948 C C O O O O O O O O O O 137
Differences in Dietary Levels of Plant and

Animal Protein of Older Women in 1948 . . 139

 

 

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III-3 o

III-4 o

III-5 o

III-6.

III-7.

III-8.

III-90

III-10.

IV-lo

IV-2.

IV-3.

IV-4.

IV-5.

IV-6.

 

Percent of Subjects Ingesting Less Than
40 Percent of the RDA for Various
Nutrients in 1948 . . . . . . . .

Biochemical Parameters of Subjects in
1948 O O C O O O O O O O O 0

Immediate Causes of Death of Subjects Who
Died in or Prior to 1972. . . . . .

Prediction Equation Relating Nutrient
Intake in 1948 and Death From Symptomatic
Heart Disease Among Subjects Dying in or
Prior to 1972 . . . . . . . . .

Incidence of Physical Disturbances Contri-
buting to Cause of Death Among Subjects
Who Died in or Prior to 1972 . . .

Prediction Equation Relating Nutrient
Intake in 1948 and Diagnosed Arterio-
sclerotic Heart Disease in Subjects
Dying in or Prior to 1972 . . . . .

Incidence of Physical Complaints in 1948
Among Subjects Who Died in or Prior to
1972 O O O O O O O O I I O 0

Age in 1948 as Related to Index of Aging
in Subjects Who Died Prior to 1972 . .

Comparison of Nutrient Intakes of Subjects
in 1948 and 1972 . . . . . . . .

Meat Varieties Chosen by Subjects in 1948
and 1972 . . . . . . . . . . .

Amounts of Meat and Eggs Consumed by
Subjects in 1948 and 1972 . . . . .

Vegetables and Fruits Chosen by Subjects
in 1948 and 1972 . . . . . . . .

Dairy Foods Chosen by Subjects in 1948
and 1972 O I I O O O O O O O 0

Amounts of Dairy Foods Consumed by
Subjects in 1948 and 1972 . . . . .

Page

140

142

151

152

156

157

161

165

192

194

196

197

200

201

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IV-8.

Iv-9 o

IV-lO.

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Page

Bread and Cereal Products Chosen by

Subjects in 1948 and 1972 . . . . . . 204
Amounts of Bread and Cereal Products

Consumed by Subjects in 1948 and 1972 . . 205
Sugars and Sweets Chosen by Subjects in

1948 and 1972 . . . . . . . . . . 208
Animal and Vegetable Fats Chosen by

Subjects in 1948 and 1972 . . . . . . 210
Biochemical Methods of Blood Analysis. . . 234
Biochemical Methods of Urine Analysis. . . 235
Incidence of Abnormalities of the Face and

Skin Among the Twenty Older Women

Examined in 1972 . . . . . . . . . 239
Incidence of Abnormalities of the Eyes,

Lips, Gums, and Tongue Among the Twenty

Older Women Examined in 1972 . . . . . 240
Incidence of Functional Abnormalities

Relating to the Cardiovascular System

Among the Twenty Older Women Examined

in 1972 O O O I O O O O O O 0 O 242

Incidence of Abnormalities of the Spine
Among the Twenty Older Women Examined
in 1972 O O O O O O O O O I O O 243

Incidence of Neurological Abnormalities
Among the Twenty Older Women Examined
in 1972 O O O I O O O O O O O O 243

Pulse and Blood Pressures of the Twenty
Older Women Examined in 1948 and 1972 . . 245

Percent of Twenty Older Women Examined in
1972 Who Restricted Their Food Intake
Because of Dental Problems. . . . . . 247

Mean Levels of Fasting Blood Constituents

for Twenty Older Women Examined in 1972
Categorized According to ICNND Standards . 248

xii

 

Table Page

V-ll. Mean Urinary Thiamin and Riboflavin Excretions
of Twenty Older Women Examined in 1972
Categorized According to ICNND Standards . 249

V-12. Dietary, Biochemical and Physical Factors
Relating to the Absence or Presence of
Abnormalities of the Eyes, Lips, Gums and
Tongue Among the Twenty Older Women
Examined in 1972 . . . . . . . . . 256

V-l3. Dietary, Biochemical and Physical Factors
Relating to General Appearance Among
Twenty Older Women Examined in 1972. . . 262

V—14. Dietary, Biochemical and Physical Factors
Relating to the Absence or Presence of
Abnormalities of the Face and Skin Among
the Twenty Older Women Examined in 1972 . 264

V-lS. Dietary and Physical Factors Relating to the
Absence or Presence of Lordosis Among the
Twenty Women Examined in 1972. . . . . 268

V-16. Dietary, Biochemical and Physical Factors
Relating to the Absence or Presence of
Cardiovascular Abnormalities Among the
Twenty Older Women Examined in 1972. . . 270

V-17. Dietary, Biochemical and Physical Factors
Related to the Absence or Presence of
Physical Complaints Among the Twenty
Older Women Examined in 1972 . . . . . 277

VI-l. Mean Anthropometric Measurements According
to Age of Twenty Older Women Examined
in 1972 O O O O O O O O O I O O 314

VI-2. Relative Weight Classifications of Twenty
Older Women Examined in 1972 . . . . . 316

VI-3. Body Weights of Older Women in 1948 and 1972. 318
VI-4. Relation of AnthrOpometric Measurements to

Body Weight of Twenty Older Women

Examined in 1972 . . . . . . . . . 322

VI-S. Basal Metabolic Requirements of Twenty
Older WOmen Examined in 1972 . . . . . 324

xiii

Table

VI-6.

VI-7.

VI-8.

VI-9.

 

Serum Measures of Glucose Tolerance of
Older Women Examined in 1972 . . .

Mean Values of Glucose Tolerance and
Cholesterol According to Age in Older
Women Examined in 1972 . . . . .

Factors Relating to Serum Measures of
Glucose Tolerance and Cholesterol of
Older Women Examined in 1972 . . .

Serum Cholesterol Levels of Twenty Older
Women Examined in 1972 . . . . .

xiv

Page

327

329

332

334

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II-l.
III-1.

1332:: -2.

LIST OF FIGURES

Dietary Supplements and Total Nutrient
Intake . . . . . . . . . .

Influence of the Amount of Dietary Fat Upon
Age at Death . . . . . . . .

Fat and Carbohydrate as Percentages of the
Dietary Caloric Intake in 1948 and Age
at Death . . . . . . . . . .

Influence of Relative Weight Upon Age at
Death 0 O O O I O O O O 0

Age Distribution of Subjects. . . . .

Number of Deaths Among Subjects in Five Year
Intervals 1948—1973. . . . . . . .

XV

 

Page

103

144

146

149

188

190

 

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.A‘

INTRODUCTION

In recent years medical advances in the conquest of
J'-I‘.1:Eectious diseases have increased the lifespan markedly.
-Iil 1900 less than one-fifth of the United States population

was 45 years or older; by 1970, one-third had attained this
EiEJ<Ee, with more than 20 million persons above the age of 65.
Many factors determine the health and longevity of
cahl~<f3er people. Over some of these, the individual has
'l‘jL‘tztle if any control (i.e. heredity, the air he breathes,
t11‘dee water he drinks, the pathogens to which he may be
GE=“‘i;E_:Josed, etc.). Diet is the one factor which for most
j‘t11iiividuals is subject to a certain amount of choice. One's
r1hl‘tritional status thus looms as an important component of
JLii-ife which may have far-reaching effects on both morbidity
and mortality. Proper nutrition throughout life has been
S‘klggested as one of the best means of minimizing degener-
£3”ti-ive changes and superimposed diseases (Irwin, 1970).
Expected life at birth has during this century

j~lixzreased from 48.7 to 74.9 years for women and from 48.2

tLCD 67.4 years for men. Correspondingly, in 1970, the

 

 

 

 

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over-65 population included 8.4 million males and 11.4
million females, respectively. In fifty years, these
numbers will have doubled (U.S. Bureau of the Census, 1970).

With these changes in population trends, emphasis

upon health care has moved from infant and child mortality

to the burgeoning problems of chronic disease. An epidemi-
Ological approach to study of a total community (Epstein
et a1., 1965) revealed that 73 percent of the pOpulation
aged 60 to 79 years, suffered from at least one chronic
Problem, either coronary or hypertensive heart disease,
d:i_abetes, respiratory disease, or rheumatoid arthritis.

Such chronic disease leads to some degree of physi-
cal disability as 42 percent of persons above 65 years of age
((3.8. Bureau of the Census, 1973, p. 82) have some limita-
1:iLon of activity, with 37 percent limited in a major way.
For one-fifth of these individuals, physical restriction is
the result of heart disease, whereas an equal number are
paxtially disabled by degenerative arthritis and rheumatism.
visual impairment, incidence of which may relate to compli-
Qa.tions of diabetes, limit the activities of 7 percent of
1:Ile retired population. Three persons/hundred have nervous
Q1": mental disorders.

Acute disablement and extreme limitation of self-
Qare, frequently necessitates institutional care of the older

citizen. In 1960 (U.S. Bureau of the Census, 1973, p. 44),
512,000 individuals resided in chronic disease hospitals

and homes for the aged. By 1970, this figure had nearly

 

 

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doubled, although the number of persons of retirement age
increased by only 25 percent. With increased mobility and
the subsequent decline of the extended family, older family
members are more likely to be cared for in an institutional
setting. Government health insurance for the elderly has
cc>ntributed to the payment of such care. In light of these
factors, facilities for the extended care of the aged are
rapidly increasing in numbers. Of the 995,000 individuals
now being cared for by institutional management, 658,000
are women. Inasmuch as the lifespan of women has been
consistently increasing, whereas that for men is remaining
S1:ationary, the number of older women will continue to
Q‘J.‘t:distance that of men. It therefore behooves us to
e3"=Ialore in greater detail, those parameters of diet and
d§i1y living which contribute to a healthy old age in
meen.
Howell and Loeb (1969) suggest that "the most
SQI‘iously needed type of related study in America is
t9 find, through long periods of time, the degree of
QOllsrelation that exists between the health records
935 individuals and their dietary habits." Some longi—
tudinal projects have been undertaken in males, in
relation to the etiology of cardiovascular disease; none
are available with women.
To correct this, the current study was begun; a
Tie-examination of the survivors of a random sample of 103

women from Lansing, Michigan, first surveyed by this

«\u

department in 1948 when they ranged in age from 40 to 88
years. Information obtained from this research may enlarge
upon current understanding regarding the influence of
dietary intake and nutritional status in middle age upon
Inatritional status and health in later years, as well as

ugoon ultimate longevity and cause of death.

 

 

 

CHAPTER I

REVIEW OF LITERATURE

Trends in Longevity
and Mortality

 

 

Li fe Expectancy

 

Advances in the control of infectious disease, with
ccbncomitant decline in mortality of infancy and early
Qliildhood, has increased the lifespan markedly during the
laneist70 years. Although the life expectancy at birth was
136:1: both sexes 48 years in 1900, females in the United
£3"'Z-‘uisttes can now be expected to live seven years longer than
rueidles, with 67.4 years being the average lifespan for men
(2(3flmpared with 74.9 years for women (U.S. Bureau of the
QQmsus, 1973, p. 57). Life expectancies for both sexes in
Q6~nada and Western EurOpe are similar to those in the
LII'1:'Lted States, albeit males in Scandanavia and the
:bq‘EVtherlands can anticipate living one year longer, whereas
‘“'<3mnen in the United Kingdom, Denmark, Australia, and New
2 ealand, generally live one year less (Metropolitan Life

II'isurance Company, 1970b hereinafter referred to as MLIC) .

 

 

 

 

 

 

 

 

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guses of Death

 

The factor contributing most to the differential
ertality of the sexes in the United States is the sex-age

related incidence of cardiovascular disease, the leading

cause of death. According to vital records (U.S. Department
Of Health, Education and Welfare, 1972c), diseases of the
heart were responsible for 38.6 percent of all deaths,
regardless of age. In spite of develOpments in drug therapy
and preventative medicine, this figure has not changed
appreciably since 1950. When other cardiovascular involve—
rue:r'nts as hypertension, cerebrovascular incidents, arterio-
SQ Jerosis, and other artery diseases are included, the death

J:‘a‘te equals 490 per hundred thousand, or 52.7 percent of all

(1% aths.

Among life insurance policy holders, deaths from
diseases of the heart have declined by 7 percent during the
last five years (MLIC. 1973); however, insured persons are
hgt strictly comparable with the general population
chause of differences by age, sex, and risk selection.
IhSurance statistics reveal that cardiovascular-renal
G‘3'1sorders were the main cause of death for males 35 years
and over, accounting for more than half of all deaths
QQcurring beyond age 50. Conversely, this syndrome of

ai~sease does not significantly influence the death rate

E’Ll’nong women until age 60, causing 50 percent of all deaths

at ages 65-69, and 70 percent at age 75 and above.

 

 

 

 

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The impact of advanced drug therapy has been

associated with the recent decline in mortality related to

hypertension and resultant cardiac damage. Statistics

(MLIC, 1972a) confirm that deaths from this disturbance

lessened by one-third for males and three-eighths for

females, during the past decade. Many deaths attributed

to vascular lesions of the central nervous system or

Chronic nephritis, involve hypertension as a contributory

factor. In respect to cerebrovascular incidents (MLIC,

19 '73c) , responsible for 11 percent of total mortality among
the general pOpulation, deaths are heavily concentrated in

the older age groups with 80 percent of these fatalities

0Q«:2urring at age 55 or above.
In 1968 the second highest cause of mortality

(I’L‘LJC, 1971) was neoplastic malignancy, resulting in 16.5

9QIl:~cent of all deaths. Cancer was the principle cause of

anth among females between the ages of 30 and 59; at ages

SS-"74, however, males experienced even higher mortality

than females. The steady rise in cancer deaths in males

has been largely the result of increased incidence of lung
Qa~ftmcer which occurs four times more frequently among men.

Malignancy at this site accounted for 30 percent of all

Qa~r1cer deaths in men aged 35 to 74, but for only 8 percent

QE such deaths of women, similar in age.

Other chronic disease states for which the death

Kate advances with age are diabetes, nephritis, and liver

cirrhosis (MLIC, 1970, 1971c, and 1973a). Diabetes,

 

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responsible for 2 percent of all deaths, is, as a contri-
butory factor, also related to arteriosclerotic involvement

of the cardiovascular-renal system.

{actors AffectingMortality

§§§.--That mortality from chronic and acute disease
Varies according to sex, has been discussed previously in
relation to cardiovascular mortality among men before the
age of 60 years. In this regard, deaths from nephritis
(MLIC, l971c) are also 50 percent higher among men at all
ages. Cirrhosis of the liver strikes only half as many
WC) men as men (MLIC, 1973a) . Inasmuch as excessive use of
a1 cohol is frequently associated with this disease, higher
QQIisumption by males may be a contributory factor. Simi—
larly, mortality from peptic ulcers was in 1967 (MLIC,
19 71d), three times higher among men. Young women are most
frequently stricken with cancer, whereas young men more

likely succumb as a result of accident.

Ragg.--That race influences morbidity and mortality
is suggested by the United States vital statistics (U.S.
BInseam of the Census, 1973, p. 57), which indicate that life
Q=ntpectancy for nonwhites is nearly seven years less than
150at whites, death ratios being doubled for nonwhite males,
and tripled for nonwhite females. Examination of circum-
S‘tances leading to death (MLIC, l971e) reveals that fatal
aL(:cidents and heart disease were increased two-fold among

nonwhite males aged 25-44, as compared with Caucasians of

 

 

 

 

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similar age; deaths ascribed to liver cirrhosis are three—
fold. Nonwhite women of middle age are more susceptible
to heart disease than malignancy, and both sexes more
frequently suffer cerebrovascular incidents than do whites.

Above age 65, no racial differences are apparent.

Place of Residence.—-One's place of residence and
VVIEIEK' of life may influence longevity and cause of death.
TIfkunj.s is suggested by the report (MLIC, 1973b) that at age
€555 , longevity is above the national average for residents
jJri- “the northwest, southwest, and Pacific regions of the
LJIfiai-ted States. On the other hand, lifespan is shortest
EiITICDImg those in New England and the middle Atlantic regions.
The highly industrialized areas of the East (U.S.
13L-131‘eau of the Census, 1973, p. 62) would seem to increase
one 's susceptibility to heart disease, cancer, respiratory
infections, and liver cirrhosis, although accidents are rela-
tively low in frequency. Incidence of heart disease and
Czéafirxiiovascular complications are decreased in the South,
t3‘31": accidents and cerebrovascular mortality are high. The
IIMCDIJntain states experience less cardiovascular and degen-
QEVITErtive conditions, but accidents and respiratory problems
E‘ITQ frequent causes of death. In the Pacific area, heart
C11Sease is infrequent, only the mountain area experiencing

Eewer deaths from this infirmity; however, accidents and

liver cirrhosis claim a highly significant number of lives.

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On the international scene, life tables from Russia,

the Netherlands, and Canada (MLIC, 1971a), show the highest

probabilities of individuals living to be 100 years. At age

65, males in Canada, Denmark, Scandinavia, and the Nether-

lands, enjoy a longer life expectancy than their American

counterparts, although lifespans of females are similar.

In Australia, England, and Wales, both sexes die earlier,

as compared with the United States pOpulation.

In respect to cause of death (MLIC, 1971b), the

only European nation to approach the incidence of heart

CiZ’Lsease experienced in this country is Scotland. Although

vital records would suggest that cardiovascular-renal
complications are less frequent in Western Europe, a measure
3f explanation lies in the terminology used in reporting

deaths.

Frequently, in these nations, the older individual

is said to have succumbed to "senility."

The United Kingdom
and Western Europe do experience higher mortality from

Q“arebrovascular complications and malignancy, than does the

U11 ited States. Conditions of weather and humidity may

e3‘lplain the high frequency of fatal respiratory infections

axIlong Britain's elderly.

Socioeconomic Status.--Many investigators have
Sought to define those factors--social, psychological, and

biOlogical, which contribute to individual risk or ultimate

longevity. A study of long-lived versus short-lived

Persons (Pfeiffer, 1970) reveals that social correlates,

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positively related, include high intelligence, sound finan-
cial status, well-maintained health with average height and
weight, continued physical activity, and intact marriage.
Such a constellation of factors Pfeiffer (1970) describes
as elite status, for these individuals may be expected
to live longer than their less intelligent, poorer
t>lc‘eathren, whose health is declining and whose marriages

11 a Ve been dissolved .

Genetic Inheritance.--There have been frequent
sll‘ggestions to the effect that longevity is largely deter-
mined by genetic inheritance, in that some factor or com-
b ination of factors, transmitted from one generation to
a:'-'1<>ther, can significantly influence lifeSpan. Hammond
and associates (1971) , upon evaluation of epidemio—
ngical data, concluded that death rates from coronary
11Eart disease were considerably higher among subjects
with short-lived parents than in those with long-lived

e:Lders. This was true for men with no history of hyper-
t:‘allsion or diabetes, of normal weight, who did not smoke
Iregularly. Life insurance statistics (MLIC, 1970a) relating
Inajor causes of death among individuals with unfavorable
family histories, reveal that those with kin exhibiting
Cardiovascular-renal disease, cancer, or diabetes, experi-

ence higher mortality from the same or related causes.

 

 

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12

Physiological Factors.-—Inasmuch as cardiovascular-

renal disorders appear in epidemic prOportions in the

highly industrialized nations, special efforts have been

directed toward defining factors of vulnerability in

respect to this syndrome. Various clinical parameters have

been considered as predictors of risk, relative to coronary

attack. Body weight and body fat, systolic and diastolic

blood pressure, smoking, stress, and serum levels of
c1"1c>lesterol, triglycerides, lipOproteins, and blood sugar,
have all been implicated in the etiology of this problem.
I<e37s et a1. (1971) and Kannel et al. (1971) reporting

J~<>r1g term studies of Minnesota businessmen and the

e‘~<11.:llt population of Framingham, Massachusetts, respectively,
QC>11clude that coronary risk is prOportional to serum

Q1’1c>lesterol levels, with systolic blood pressure and

SITl<>king habits important components.

A report (Ward, unpublished data, 1972) examining

rtl(Drtality experience over a seven year period in relation
to physical measures, confirms the fact that age and sex

are important in predicting lifespan, even in a pOpulation

whose age averages 74 at the time of survey. It was

flirther suggested that after age and sex, the EKG and blood
SIlgar, along with urine protein, sedimentation rate, and
blood urea nitrogen, are particularly significant indi-

Cators of risk.

Obesity, a prominent public health problem in the

industrialized nations, may be a very significant

l3

determinant of lifespan in that it enhances the deve10pment
of degenerative disease. Jolliffe (1953) hypothesizes
tflnat a cure for obesity would increase life expectancy
13); as much as four years, whereas a cure for cancer
would increase it by only two years. Life insurance
Statistics infer that death ratios are 50 percent higher
( £3<3c. Actuaries, 1959) in respect to all leading causes
<:>:ff death, for those individuals 20 percent or more above
<51<E=£sirable weight. A study of mortality (Comstock et al.,
1 966) among the population of Muscogee County, Georgia,
I5>ZI=T<3vides evidence that deaths resulting from diabetes,
<:=<:=b:r:onary heart disease, accidents, strokes, and hyper-
itlealnsion, were strikingly associated with fatness.

Goodman (1955), studying the effect of obesity
isllruang 135 chronically ill patients, reported that the
<:>‘errweight subjects were, on the average, five years
:5’CDIJnger than those of normal weight. Relative to improve-
It‘Gént upon weight reduction, obese diabetics, previously
‘El€319endent upon insulin, usually became aglycosuric following

loss of body weight. Conversely, satisfactory regulation

eVen with insulin was unattainable among the obese. In
1:‘egard to osteoarthritis, a frequent cause of disability
Eu“Ong older subjects, physical therapy cannot restore
I“Obility in the overweight without concomitant weight

reduction (Traut and Thrift, 1969) . The avoidance of

 

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excessive accumulation of body fat would appear to be one

of the more effective means of insuring a long and healthy
life.

Nutrition and Longevity

H i storical Perspective

Since antiquity, men have been concerned with the
relationship which exists between nutrient intake, mor-

bidity, and mortality. A Biblical narrative (Holy Bible,

RSV, Daniel) discloses that young Jewish men, given vege-

tables to eat and water to drink, were at the end of ten

days "better in appearance and fatter in flesh than all the

youths who ate the king's rich food." The writer of

PZli‘caverbs (Holy Bible, RSV) counsels his followers to "be

11<31: a winebibber or gluttonous eater of meat."

In later times advice was directed toward possible
r“eans of increasing the lifespan, with suggestions relating

to one's choice of food and drink for health and well-

being in old age. Cornaro, in the fifteenth century

(Beeuwkes, 1952) , thought it advantageous for an old man to
eat but little, the writer suggesting that it was the over-

quantity which injured, even more than eating unsuitable

feed. Eylot (Beeuwkes, 1952), in one of the earliest

I“edical books published in vernacular English (1534) urged

the choice of meats, easily digested, and recommended that

wine be served with meals.

15

In his treatise (Beeuwkes, 1952), Francis Bacon
stated that "M well ordered bears the greatest part in
the prolongation of life," and suggested a spare diet as

would be prescribed by the strict rules of a monastic life.

One of the early works in the field of geriatrics, published
by Hufeland in 1796 (Beeuwkes, 1952), contains many prin-
Ciples emphasized in modern thought. Young peOple are
advised to avoid sugar and confectionary, choose vegetables
in large quantity, and limit the amount of meat consumed.
one should eat sparingly at night, and never eat so much
that one can feel he has a stomach.

In more recent times, Metchnicoff (1910), the

Ru ssian physiologist, pursued the theory of auto-
intoxication suggesting that death occurred as a result
Qf accumulated toxins within the body. Putrefaction
Q(Duld be avoided by the frequent consumption of yogurt, a
food containing lactic acid-producing bacteria which might
destroy the intestinal microbes responsible for producing
the toxins. He cited examples of the long-lived peoples
in Russia who daily consumed fermented milk, as proof of

his. idea.
man Nutrition Studies

Longelived Populations.--Modern scientists have
Pursued the study of longevity by examining individuals in

those cultures where a long life is common, in the hOpe of

 

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16

defining those factors of diet or daily pattern which seem
to encourage a healthy and robust old age. Several investi-
gators (Toomey and White, 1964; Davis, 1973; and Leaf, 1973)
have studied three groups of people among whom a significant

preportion of individuals are reported to live to age 100

years or more, yet, remaining in vigorous health.

One such p0pulation is the village of Vilcabamba

S ituated in the Andeas Mountains of Ecuador, a totally

agricultural community raising vegetables and grains.

In
1 9 '71 (Leaf, 1973), 7 percent of the people were aged 80

years or more, compared with less than 1 percent in Ecuador
as a whole.

The dietary pattern in Vilcabamba is almost
e='-=<:1usively vegetarian, with a daily caloric intake of
about 1200 kcal.

The protein and fat consumed,

35-38 grams
and 12-19 grams respectively, are mainly of vegetable

Qt‘igin, with animal sources providing only 12 grams of the
daily protein.

The preponderance of calories are obtained
from carbohydrate foods.

Another investigator (Davis, 1973) estimates the
Qaloric intake of these people to equal about 1700 kcal,

but concurs in the opinion that meals are frugal. The meal
pattern consists of soup prepared from grains, corn, beans,

and potatoes, sometimes augmented with oranges and bananas.

Meat is consumed at a level of one ounce per week.

What
little milk is available is made into cheese.

Inhabitants
Consume large quantities of homemade rum, but only small

amounts of unrefined sugar.

17

A second population possessing many long-lived

members is found in the province of Hunza, in Kashmir. As

the village in Ecuador, Hunza has an agricultural economy

(Leaf, 1973). The farmers raise vegetables, grains

(barley, wheat, and millet), fruits, and nuts, but seldom

LS there enough to last through the severe winter. As a

result, there is annually a period of semistarvation. Even

throughout the productive seasons, energy intake among
“La les is, by American standards low, averaging 1932 kcal.

The typical diet is composed of 50 grams of protein,

35 grams fat, and 354 grams carbohydrate, with less than

one percent of the total daily intake derived from animal

SQlarces. Milk and milk products are absent. Meat, pri—

marily mutton, is eaten only once or twice during the year,

usually as part of a festival celebration.
The work of Hejda (1968) would confirm those

ObServations of the Hunzas suggesting a positive relation
bQ‘tieen limited food supply and longevity, as the oldest
people in Czechoslovakia frequently experienced what was
deseribed as an "inadequate" diet, in that they remembered

a .
8 Children, frequently experiencing hunger.

A different picture is presented of dietary pattern

1“ the Caucasus Mountains of the U.S.S.R., a mixed

grlculture-dairy economy where animal products are consumed

daily (Leaf, 1973). Aged Georgians consume milk, cheese,

and yogurt three times a day, and meat servings are

 

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frequent. The actual daily consumption for those above 50

years of age has been reported as 1800 kcal, with 60 grams

fat. An occasional feast may include mutton, goat cheese,

beef, green onions, garlic, spicy sauce, and wine. Obesity
has been observed among the older pe0p1e.

Despite the problem of accurate documentation of
age among the subjects observed in Ecuador, Pakistan, and
the Soviet Union, it would appear that individuals enjoy
J—C>ng and healthy lives, actively participating in the

physical work and social life in the community. No evidence
of coronary heat disease (Toomey and White, 1964) as noted
by EKG tracings was found among aged Hunzas, for whom serum
cIlolesterol averaged 172 mg percent. Of seven centenarians
Q:rtamined in Ecuador (Davis, 1973) four were diagnosed as
hOrmal. Relative to dietary factors, observation of these
Deeples would suggest that a low to moderate caloric intake,
1 imited in animal protein and saturated fat, is conducive
to a long and healthy old age.

Examination of 27,000 individuals over 80 years of

age in the Soviet Union (Chebotaryov and Sachuk, 1964)
revealed that 91 percent consumed a mixed diet, with
Vegetarians comprising only 8 percent of the pOpulation.
one of the subjects, however, ate a predominately meat diet;

almost all were lean in build.

19

Longitudinal Nutrition Studies.--Studies in the

United States, examining total dietary intake in relation to
length of life, have been limited in number. Kelley and
coworkers (1957), who examined a random sample of 97
.Michigan women between the ages of 40 and 88 years, noted
that physical well-being was directly related to nutrient
intake. Physical complaints, as pains in the joints or

unexplained tiredness, were more frequent among those with

diets low in one or more nutrients. Mortality over a seven

Year period was higher in those subjects reporting less

than 40 percent of the Recommended Dietary Allowance (RDA)

f or at least one nutrient.

A four year follow-up of 577 California residents
Over 50 years of age (ChOpe, 1954) revealed higher mortality
rates associated with lower intakes of vitamin A, niacin,
and ascorbic acid. Subjects with hemoglobin levels below
13 gm/lOO ml suffered a higher incidence of respiratory
disease, whereas low intakes of vitamin A (below 5000 I.U.)

Were correlated with disorders of the nervous, circulatory,

and respiratory systems. When dietary thiamin was low,

<3.iseases of the nervous and circulatory systems increased;
hOwever, high intakes of ascorbic acid were related to low
incidences of these problems.
Waters and coworkers (1969) studying mortality over
a ten year period among 723 British subjects, suggest
that those individuals with hematological values near

the mean may have lower subsequent death rates. Men

 

 

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20

for whom blood packed cell volumes (PVC) measured more than
one standard deviation above the mean (45.70 i 3.08) suf—
fered higher mortality; 20 deaths against the expected 10.6
deaths for this group. Higher death rates occurred among
both sexes with low serum iron levels. These reports,
éalthough limited in number, would suggest that either
inadequate dietary intake or impaired utilization of vita-
:nlins or minerals, may predispose the individual to particu-

lar physiological disorders.

Macronutrients and Longevity.-—Recently, attention

 

11513 been drawn to the intake of particular macronutrients,
namely calories, fat, and carbohydrate, as they might
:irifluence mortality, especially in relation to cardio-
vascular disease. Food disappearance data would suggest
‘tJIat the caloric intake per capita (Swope, 1970) has
declined over the past 60 years from 3490 kcal in 1909 to
33240 kcal in 1969. During this period, however, the
Sources of these calories have changed. Fat comprises a
greater portion of the diet, increasing from 32 percent
‘txb 42 percent of total calories, while carbohydrates have
declined from 56 percent to 46 percent of total calories.
lklthough protein intake on an absolute basis has remained
<20nstant, animal sources which contributed only one-half
*Of protein calories in 1909, now account for over two—

thirds of dietary protein.

 

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Several investigators, attempting to relate these
changes in the food pattern with the significant increase
in cardiovascular mortality, have compared the consumption
of macronutrients in this and other countries with

differing rates of cardiovascular deaths. Weiss and
Mattil (1957) assembling data showing the levels of
meat, eggs, fats and oils, and total kcal, consumed in
25 countries, found impressive coefficients between the
consumption of meat, eggs, and fat, and incidence of
arteriosclerotic heart disease. Total caloric intake,
however, showed the highest correlation with coronary
fatality. These authors point out that dietary levels of
food and fat are also positively correlated with measure-
1Tlen'ts of well-being (i.e. percentage of the population
reaching the age of 40, and life expectancy at age 40).
one could question whether the relationship between food
and fats, and atherosclerotic deaths may not result
partially from the beneficial effect of these nutrients
llipon longevity.

Similar conclusions were drawn by Watanabe and
aSsociates (1968) upon looking at total calories,
a~rlimal protein, and fats and oils, consumed in advanced
a~I‘Ld underdevelOped nations. The higher the nutrient

iIltake, the more favorable the lifeSpan. Examination

of nutrient intake from the advanced nations only yields

22

the Opposite interpretation. However, it must be

recognized that other factors as poor sanitation and
inadequate medical care also contribute to the higher
mortality ratios in the less develOped nations. By

regression analysis, the inflection of the curve, where
(nutritional influence changes from better to worse, occurs

.at.an intake of 3000 kcal, 90 grams protein, 50-60

gyrams fat, and 35-40 percent of calories of animal origin,

Jrespectively. The quantity of meat consumed provided the

sstrongest association with degenerative heart disease

among the advanced nations studied.
Soukupova and Prusova (1970) evaluated nutrient

iJitake and ischemic heart disease incidence in 33

cnauntries. Sex differences were observed, in that
lmeart disease in males was most closely related to dietary

fat; in females, total calories were most significant.

Tlfine coefficient for sugar was low for both sexes. In

JEWEgard to this epidemiologic evidence, not only is the
'1:<>tal quantity of food ingested a significant factor, but

'Eiilso the relative percentages of fat, protein, and carbo-

hYdrate calories .
In respect to changes in dietary pattern among the

ljundustrialized nations, not only has total carbohydrate
‘<3eclined, but differences in composition have become

Eapparent; the consumption of sugar has increased while that

of complex carbohydrate has decreased. Considerable

23

controversy has ensued regarding the role of sucrose as a
causal factor in the deve10pment of coronary heart disease.
Yudkin (1972) reported that young men fed high amounts

of sucrose showed increased levels of serum triglycerides
after only two weeks on the diet, and one-third of the
.subjects demonstrated a rise in plasma insulin, plate-

let adhesiveness, and body weight, all symptoms of atheros-

Clerotic patients. Keys (1971) disputes these findings,

charging that all experiments were of short duration,
and levels of sucrose fed were several times that found
in natural diets.

The incidence of diverticulosis and colonic cancer
in the western world has increased markedly in this century,
now affecting one-third to one-half of persons over the age

Of 40. Painter and Burkitt (1971) , drawing upon epidemio-

logical evidence suggest this disease to result from a

<ieficiency in fiber, as dietary habits have shifted to

use of refined cereals. Diverticulosis is rare in those

parts of the world where high residue diets are common-
place. In like manner, deaths from colonic cancer have
Paralleled the increase of diverticular disease, with
this form of cancer being the second most common among
both sexes in the United States and Canada (MLIC, 1971) .
The dietary replacement of complex carbohydrates with sugar

and refined cereals would appear to have an unfavorable

effect upon health and well-being.

24

Much debate has surrounded the aspect of dietary

fat in the etiology of atherosclerosis and degenerative

heart disease. In addition to the increased consumption

of lipid, attention has focused on the degree of saturation

and chain length of fat moieties, as well as the dietary

<:oncentration of essential fatty acids. Changes in serum

a known risk factor in the occurrence of

cholesterol,
been the result

(Lardiovascular problems, have not, however,

cxf changes in dietary fat over the past 60 years. Compu-

1:61tions by Kahn (1970) reveal that known changes in the

Ifxood pattern could not solely have caused observed

<flgifferences in cholesterol response and cardiovascular

mortality .
Inasmuch as heart disease strikes men of middle

elge, whereas women before the age of 60 are practically
limmmune, Friedman and Rosenman (1957) compared the fat
Cilrtake of upper class husbands and wives in the San
Francisco area in relation to this clinical disease.
:IRsesults confirm that although males consumed more calories
'Eirmd consequently more total fat, calculated intakes on the
basis of body surface area did not differ, equalling 387
iElnd 409 for the men and women, respectively.
One negative aspect of diets specially formulated
tl‘b reduce serum cholesterol by increased intake of unsat-
ttrated fats, has been reported by Pearce and Dayton (1971).
Among their male subjects, a decrease in atherosclerotic

Iflsk was accompanied by a higher incidence of cancer.

25

Alternatively, Ederer and coworkers (1971), editing data
compiled from four clinical trials in various locations,
found no evidence of increased cancer mortality.

Although it would appear that the level and degree

of saturation of dietary fat is a factor in the develOpment
(3f cardiovascular disease in males, no such evidence exists
iJn respect to females.

Disturbances of the kidney are a problem which
lirlcrease in severity with advancing age. Among normal
-11€ealthy aged, kidney function at age 60, is approximately
55(1—60 percent that observed at age 30 (Shock, 1968). With
‘63 «decrease in the number of functioning nephrons, filtra-
‘t:iJon rate declines, with a consequent rise in blood urea
itljutrogen. One possible means of alleviating the problems
Qf kidney impairment might be a change in the type or

‘;Ilmantity of ingested protein, thereby altering the levels
c5f urea produced.

Bolourchi and coworkers (1968), studying physio-
:l-Cmgical responses in young men changed from a typical

latnuerican diet with protein of primarily animal origin to
63- Iregimen consisting entirely of vegetable protein fed
ji-Il the form of bread, noted a marked reduction in blood
‘Qlltea. Previous investigators (Lyon et al., 1931) indi-
<2fitted that patients with chronic nephritis demonstrated
El marked, long-term improvement when given sodium bicar-
bonate, an alkalinizing agent. Blood urea nitrogen was

reduced to non-toxic levels. The authors suggested that

26

any foods producing an alkaline reaction in the body may
favor the maintenance of normal kidney function. This
could be accomplished by the substitution of protein from

vegetable sources (alkaline in nature) for animal foods

(enhancing formation of acid). Whether such a reversal of

the dietary pattern of the Western nations could effect a
reduction of chronic kidney disorders with a concomitant
increase in life expectancy, is a postulate deserving of

further investigation.

glimal Studies

In the twentieth century, investigators have begun

tx: explore, using animal models, those combinations of

Clietq varying in both quality and quantity, which increase

lxongevity while reducing morbidity.

Food Restriction.--McCay and coworkers (1943) the
iiirst of modern scientists to investigate this relation,
Showed that the amount of food consumed significantly

lirtfluenced disease incidence and length of life. Rats fed

ea. diet so limiting in calories as to retard growth and
delay sexual maturation, enjoyed a 40 percent increase in
lifespan. Upon analyzing the effects of food ‘restriction,
1t§lpe and level of dietary protein, dietary supplements,
Eindexercise, the single most important factor influencing

longevity was determined to be the amount of body fat.

‘Yfistologically, the tissues of the lean, older animals were

 

 

 

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27

similar to those of younger animals. Inasmuch as equal
numbers of male and female animals enjoyed longer lives,
it*would seem that growth retardation equalizes the
lifespans of both sexes.

Berg and Simms (1961) determined that rats whose
food intake was restricted to 54 percent that given
chntrols displayed only slight retardation in skeletal
gxnjwth and rate of maturation, despite the absence of
depot fat. Restricted animals lived longer, exhibiting
delayed onset of myocardial, vascular, and renal lesions.
Because a single variable, caloric intake, influenced the
Esequence of lesions in all tissues examined, these authors
IPostulate that a common factor exists to control the onset
‘Df aging and disease, and that adjustment of nutrient
Slipply can affect it.

Indirect support for their hypothesis emerges from
‘the‘work of Carlson and Hoelzel (1946, 1948) who observed
ElProlonged lifespan in those rats for whom caloric levels
‘mere reduced by intermittent fasting, or the addition of
inonmetabolizable bulk-formers to the ration. Everitt

(1971) evaluating biological age by determining the breaking

53trength of collagen fibers, noted that rats restricted in

t:heir feed intake were, at 900 days of age, biologically

(Esimilar to control animals only two-thirds that age.
~3§Ldministration of thyroid hormone (Everitt et al., 1969)

£1:r—esulting in a 39 percent increase in food consumption

\VHI— \

28

by the mature rat, accelerated significantly the aging

of tail tendon fibers. In relation to susceptibility

to disease, Grewal (1971) demonstrated that animals

fed 50 percent of the feed consumed by ad libitum

fed controls, were upon post-mortem examination, free of
chronic respiratory infection, whereas control lungs con-
tained nodular cysts and hemorrhagic areas.

It can be concluded on the basis of animal experi-
nuants that caloric restriction to a degree which prevents
tine accumulation of depot fat while permitting the normal
sequence of maturation, significantly increases the
Zlifespan. The leaner animals appear younger, with no

increase in susceptibility to disease.

Macronutrients and Longevity.--Ross (Ross, 1972;
31kms and Bras, 1973) considering the effect upon life
exPectancy of a single lifelong dietary regimen, tested
Semisynthetic formulas varying in protein and carbohydrate
Itatios, each fed on a restricted or non-restricted basis.
lldmiting the intake of the protein component only, with
lisocaloric substitution of corn oil or sucrose, changed
t:he lifespan but little. Restricting carbohydrate enhanced
JLife expectancy only with simultaneous restriction of

Calories. A low intake of both protein and carbohydrate,
'JL.imited in calories, produced no effect early in life;

however, restricted intake of this protein-calorie ratio

29

1:5 enhanced life expectancy to the greatest degree,
reducing the incidence of chronic disease. Length of life
was related to final body weight; for every 10 percent
reduction in body weight, a 13.5 percent gain in life
eXpectancy was realized. Lighter animals were more immune
to ne0p1astic growths, whereas the incidence and severity
«of glomerular nephritis was directly related to intake of
protein.

Other studies (Miller and Payne, 1968) investi—
gating the efficacy of varied levels of dietary protein
revealed that rats fed a diet high in protein during the
19eriod of rapid growth, and low protein thereafter,
Icemained in good physical condition, were lean, and lived
:28 percent longer than controls continued on the high pro-
1:ehn:regimen. In contrast, no significant differences in
.deespan were noted by Nakagawa and Masana (1971) among
Enfimals given diets containing 10 percent, 18 percent, or
27 percent casein.

Although a low protein diet does not in itself
.increase the lifeSpan without concomitant caloric restric-
‘tion, excessive intake may enhance degenerative disease.
ZEn rats, the incidence and severity of glomerular nephritis

Vvas directly related to the level of dietary protein.

Another component of the diet examined in relation
1:0 morbidity and mortality has been fat. Mice fed a diet

Q<3mposed of 29 percent fat (lard), by the Silberbergs

30

(Silberberg and Silberberg, 1954) suffered higher mortality
regardless of strain, sex, age, or weight gain. The
deleterious effect of the high fat regimen was more con-
spicuous in animals of a long-lived as compared with a
short-lived strain; in males than in females; and when fed
from the age of one year rather than from weaning. The
rate of mortality was assoCiated with the degree of body

weight increase.

Similarly, French and coworkers (1953) noted a
significant decrease in length of life among rats of both
sexes fed a diet containing 22.7 percent corn oil.
Histological examination of those animals revealed high
liver fat content among males fed the corn oil ration,
as compared with controls fed the basal carbohydrate
mixture; however, the cause of premature death could not
be ascertained. The increased efficiency of utilization
Sefiin with the high fat ration, was correlated with the
deCrease in lifespan.

Schemmel and coworkers (1973) studied rats suckled
by dams fed either a high fat (60%) or grain (3% fat) diet,
and then weaned to either the high fat or grain ration.
After 168 days, the only group in which no deaths had

cmmurred was that suckled by grain—fed dams, and subsequently

continued on the grain. Mortality was highest for those
nursed by the high-fat fed dams and weaned to the high fat

tration. Connective tissue obtained from rats fed a high

31

fat ration (60% animal fat) was found to contain con-
siderable lipid (Svojtkova et al., 1972), which may lead
to cumulative cross-linking and accelerated biological
aging.
Many investigators have directed their efforts
toward elucidation of potentially toxic substances which
I may be responsible for the lethal effects of dietaries
high in fat. Thomasson (1955) who fed to rats diets
composed of either 50 percent rapeseed oil or butterfat,
observed more rapid growth, higher weight gains, increased
incidence and severity of kidney lesions, and shortened
lifespan, in those receiving the animal fat. The differ-
' ences in lifespan could not be explained simply on the
baSis of the presence of erucic acid, an appetite and
grovwhrinhibiting factor naturally occurring in rapeseed
oil,
Unsaturated fats are known to be highly susceptible
' to oxidation with the subsequent formation of peroxides,
‘ implicated in deleterious free radical reactions (Harmon,
1969). Morin (1967) noted no differences in longevity or
liver peroxide content in several strains of mice fed
stock diets supplemented with sucrose, safflower oil, or

hydrogenated coconut oil. A three-fold difference in

éliver storage of linoleic acid did occur among those

:ingesting the unsaturated fat.

 

 

 

 

 

 

 

32

When Poling and associates (1970) fed heated
(oxidized) animal and vegetable fats as 20 percent of a
nutritionally adequate diet to rats of both sexes, no
differences in longevity were exhibited in respect to
those fed the non-heated substances. Animals receiving
hydrogenated vegetable fat, whether heated or non-heated,
enjoyed the longest lives.

In contrast to these findings, Kaunitz et al.
(1970) concluded from his studies that fresh olive, soy-
bean, and corn oils contain, despite processing for human
consumption, components which are toxic to rats. Improved
rates of survival were seen among those fed oils which
had been subjected to mild heating and aeration. Analysis
Of results testing a variety of animal and vegetable fats,
Either oxidized or not, fed as 20 percent of the ration,
Suggests that longevity as well as degenerative diseases
which occur in rats (i.e., lung infection, renal lesions,
etc.) do not correlate with any of the currently popular
fat parameters as linoleate content, melting point or
degree of unsaturation. Lower death rates were associated
With beef fat and medium chain triglycerides, both low in
linoleate, but widely differing in melting point. Animals
fed corn oil lived longer, but displayed severe cardiac
changes. Components of the non-triglyceride fraction may

be involved in these lipid-induced disturbances.

 

 

33

The deleterious effect of dietary fat upon the
lifespan of experimental animals has been well established.
Although this decrease in longevity is mediated in part by
excessive weight gain and fat infiltration of vital organs,
it would appear that toxic substances present in the fat

may also contribute to degenerative disorders.

Increased intake of refined carbohydrate in the
human diet has stimulated research with animal models in
light of possible relationships to induced hyperlipidemia
and cardiovascular disorders. Early investigators fed
large quantities of carbohydrate compounds to rats with
differing results. McCay and coworkers (1952) found no
apparent differences in lifespan or tissue histology in
those rats given a stock diet with a 10 percent sucrose
SOlution for drinking. Feeding cornstarch in a sufficient
quarujty to produce overweight, equivalent to that of mice
receiving a high fat ration, did not alter mortality
Patterns among those strains studied by the Silberbergs
(Silberberg et al., 1955). Rats fed a 30 percent lactose
ration by Whittier and associates (1935) accumulated less
Indy fat, and lived longer than those given isocaloric
levels of sucrose; however, total food consumption by both
*groups of animals was not reported.

Further deleterious effects resulting from sucrose

.ingestion have been cited by Dalderup and Visser (1971)

 

L

34

and Al-Nagdy et a1. (1970). The Dutch investigators,
comparing Wistar animals fed sucrose at levels of 14.5 per-
cent or 30 percent, observed higher mortality and pre-
mature incidence of severe glomerulonephritis among males
fed the sweeter ration; females were not significantly
affected. Diets high in sucrose (64-80%) increased serum
cholesterol, decreased glucose tolerance, and increased
liver fat, in adult rats (Al-Nagdy et al., 1970). In
experimental animals it would seem that the detrimental
effect of Specific carbohydrates upon the lifespan is the

result of high caloric intake with excessive weight gain.

Micronutrients and Longevity.--Relative to the
micronutrients, investigators, early in this century, con-
Oentrated their efforts upon the determination of Optimum
leveds of the newly isolated factors, eventually classified
as vitamins. Sherman and others (1945) discovered that
although vitamin A fed at levels of 0.8 1.0. per calorie
was adequate to maintain 58 generations of rats of the
OSborne-Mendal strain, a doubling of dietary vitamin A
deferred old age, thereby increasing the length of life.

A recent concern of nutritionists has been the role
of free radical reactions and lipid peroxidation in the
degenerative changes associated with aging. Inasmuch as
‘vitamin E performs as a biological antioxidant, investi—

«gators have tested varying levels of both this nutrient

 

3S

and synthetic antioxidants in relation to fat content of
the diet and ultimate longevity.

Kohn (1971) observed that addition to the diet of
antioxidants as mercaptoethyamine hydrochloride extended
the mean survival time of mice to optimal control values,
but maximum values were not increased. Apparently these
substances inhibit harmful environmental or nutritional
factors which in some experiments cause premature death.

Tappel and coworkers (1973) supplemented the basal
diet of their rats with varied amounts of known biological
antioxidants including alpha toc0pherol acetate, ascorbic
acid, methionine, and sodium selenite. Although relative
mortality did not change, the animals receiving high levels
0f antioxidants had significantly less accumulation of
fluorescent pigments in the testes and heart. Concentration
0f such pigments is considered to be a consequence of aging.
The lifespan cannot be increased by vitamin supplementation
above those levels required for normal growth.

Atmospheric pollutants, resulting from industrial
Vmstes, have led Schroeder and coworkers (1964; 1968) to
Examine the effects of trace minerals upon the lifespan
(Ifnuce. Cadmium, titanium, and lead fed at 5 ppm in the
(Srinking water, significantly shortened the life, although
1tissue concentrations were similar to those observed in
Iduman tissues. No metal proved to be carcinogenic, but all

Eexhibited signs of innate toxicity. In contrast, rats fed

\J

 

36

chromium at the above level experienced an increased rate
of growth with higher body weights. Including tin in the
driJnking water, resulted in liver fat deposition and renal
turnilar degeneration, although tissue concentrations were

minimal.

That not only diet composition but also the manner
Ihl‘flhiCh it is consumed can influence longevity, has been
suggested by work of Leveille (1972a), as meal—fed animals
lived significantly longer than nibblers. One possible
exPlanation is the lower body weight and body fat of the
meal-fed animals who consumed 25 percent less food than

nibblers .

Nutrient Requirements
of Older Pegple

 

 

Although much effort has been invested in defining
the nutrient requirements at various ages and stage of the
life cycle, little is known regarding possible alterations
in nutrient needs as a result of the progression from
middle to advanced age. Present evidence would suggest

that requirements differ for only one nutrient, energy

calories. With the change in activity level, as well as
body metabolism, previous intake is excessive, and if con-
tinued, results in insidious weight gain. No conclusive

data has been derived to confirm that the requirements for

protein, vitamins, or minerals, differ in healthy aged as

compared with young adults.

 

 

37

Fac tors Affecting Requirements

Digestion.--In attempting to examine the nutrient

 

recpairements of older people, one consideration has been
possible changes in the efficiency of digestion and
absorption of foodstuffs. Although the effects of physio-
logical aging of the gastrointestinal tract could alter
both anatomical structure and function, Berman and Kirsner
(1972) suggest that digestive problems in later years often
reflect other difficulties. Chronic disease may impair
general health, thereby limiting physical activity, creating
emOtional disturbance, and necessitating continued use of
drugs. Other physiological factors as changes in protein
metabolism and enzyme synthesis, a decrease in regional
blood flow, and reduced somatic muscle tone, may result in

clinical symptoms, according to Geokas and Haverback (1969).

Enzyme Production.--Meyer and Necheles (1940)

 

comparing basal and stimulated salivary secretion in young
and old adults, noted markedly depressed basal levels of
salivary amylase among the latter. Following stimulation,
pancreatic amylase secretion did not differ between the two
groups of subjects. Further studies examining gastric
enzyme levels in 26 aged persons (Fikry, 1965) revealed
that the volume of gastric juices was only 75 percent of
normal, although acid concentration was unaffected. Fikry

considers this reSponse to reflect both a decrease in

38

runnlaer of parietal cells plus the impaired capacity of
available cells. Despite changes in pepsin concentration
1 and acid volume, no subject complained of gastrointestional

discomfort .

In regard to stomach motility, no difference in
stomach emptying time following a high carbohydrate test

meal, administered to young and old men, was noted by

Van Liere and Northrup (1941).
3 Absorption Mechanisms

Carbohydrate Absorption.--In respect to energy

requirements, experiments with both animals and humans

// WOUId imply that intestinal absorption is not a significant

/ factor. Klimas (1968) measuring glucose absorption by
means of an intestinal loop in male rats, observed a
significant increase in the ability of the gut to absorb
this nutrient throughout the first ten months of life;
there was no discernible change from that time through the
third year.

Early studies of hexose absorption in humans, using
galactose as a test substance (Meyer et al., 1943), demon-
strated a 30 minute lag in the appearance of this sugar in
the blood of older subjects (mean age 76.6 years) as com-
pared with young volunteers (mean age 20.5 years). Total
absorption, independent of the time factor, could not be

ascertained.

 

 

 

39

Guth (1968) studying active absorption of pentose,
repmazrted delayed xylose excretion following the sixth
decade of life; however, this effect might reflect
<dimiJ1ished renal function as well as impaired absorption.
Plasma xylose two hours following administration did not
‘vary';in subjects aged from 30 to 79 years. Although the

appearance of absorbed sugars in the blood is delayed in
older subjects, possibly as a result of reduced cardiac
output and organ perfusion, it has not been shown that

total absorption is reduced.

Fat Absorption.--Several investigators examining
fat absorption in young and old adults, provide evidence
that both rate and degree of total absorption may decline
in later years. Lipoprotein lipase concentration is
diminished in the intestine.

Becker and coworkers (1950), estimating fat
absorption by the chylomicron technique, noted a signi-
ficant drop in the absorption rate in older subjects, a
phenomenon which could be altered by the administration

of lipase or Tween 80. Following ingestion of 131I-

triolein, a peak in plasma 131I was seen after three
hours in the younger subjects, whereas concentration
reached a maximum in the older individuals after a period

of five hours (Matsumoto, 1968). Evidence suggesting

lowered production of pancreatic lipase comes from the work

40

of I?eelz and associates (1968) who observed that 17 of 43
older persons, all free of symptoms of organic disease,
exluilaited stool fat content above 20 percent of dried
‘weiglit. In ten subjects, Split fat was less than 42 per-
cent of total fat.

According to Werner and Hambraeus (1972), when
eight.subjects aged 67 to 72 years were fed 115 grams of
fat daily, equally divided among all meals, the diet was
well tolerated. If over one-half of the fat was consumed
at one meal, fecal fat increased proportionately. In that
free fatty acids did not appear in the fecal mass, the
insufficiency likely related to decreased enzyme production.

Although older individuals would appear to have
decreased efficiency in digesting and absorbing fat, the

problem may be circumvented by equally dividing fat intake

among all meals.

Protein Absorption.--A primary concern has been the
totality of protein digestion, in that lowered volume and
acid content of stomach fluids has been demonstrated in
older people (Fikry, 1965), Draper and Lowe (1958) could
find no relation between efficiency of protein digestion
and age in rats fed a reference sample of nitrogenous

foodstuff with a ferric oxide marker.

The rate of digestion and degree of absorption did

not differ in the young and old subjects given a test meal

of 1131-1abe1ed albumin by Chinn and others (1956).

In

 

 

 

 

 

 

41

L131

of :1 -labeled albumin by Chinn and others (1956). In

only one of the 12 older persons (aged 72-88 years) did
less; than 10 percent of the ingested isotOpe appear in the

‘blocxi within a period of two hours.

Studies on the molecular level have tried to
elucidate possible differences in the mucosal transport

of amino acids in the aging organism. That uptake of

amino acids is related to body need as well as anatomical
integrity is suggested by the work of Penées (1970) who
noted that 1-arginine was absorbed more rapidly in vivo by
Young growing rats than in either young or old animals.
Measures of specific activity would indicate that reduced
passage across the intestinal wall of old animals results

from reduced blood flow, with slowed removal of the sub-

stance by the cells. In respect to lysine which remains

essential throughout the lifespan of the rat (Penzes, 1969)

absorption and utilization as measured by the disappearance

of l-lysine-14C, was not significantly different in old

(27 months) as compared with young (2.5 months) rats.

Of special concern in senescence are the sulfur-

containing amino acids, as Barrows and Roeder (1961)

suggest that sulfhydryl groups may inactivate free

radicals. Animal studies indicate a higher degree of

35

absorption of S -amino acids in old than young rats, as

Penies and associates (1968) discovered that older animals

utilized 23 percent more of an administered dose than did

young controls. That increased absorption is a reflection

 

42

(3f gassed is implied by Winter and colleagues (1971) who
found that absorption of cystein—S35 was significantly
less; in old animals pretreated with a cysteine complex,
'thari in non-treated animals of the same age. Digestion
of gxroteins and the absorption of amino acids do not seem

to km; significantly altered as a consequence of advancing

age 0

Calorie and Energy Needs

The only requirement for which existing evidence
Suggests a change with the progression from middle to
advanced age, is energy calories. That caloric intake
is not always decreased proportionately with reduced need
can be inferred by the high incidence of obesity among the
older populations in the Western countries. Consequently,
the RDA for calories as established by the National
Research Council, is surrounded by much controversy.

A study of 32 Nebraska women (Fry et al., 1963)
ranging in age from 65 to 85 years, revealed that no sub-
ject consumed less than two-thirds of that recommended,
with the mean intake of 1696 kcal representing 94 percent
of the standard. Similarly, a study of 100 Bostonians
(Lyons and Trulson, 1956) over 65 years of age revealed
that energy intake was, among the women, 1831 kcal or
102 percent of the RDA, whereas the men consumed 2458 kcal

or 94 percent of their recommended level.

 

43

On the other hand, Swanson and coworkers (1959)
noted that the energy value of the diet dropped precipitously

after 70 years of age among women of the North Central

:regixan. Calories numbered 1630 in the seventh decade as

compared with 1353 for decades beyond. Conversely, 60

British women in the eighth decade of life were reported to
consume 1890 kcal daily (Exton-Smith and Stanton, 1965) .

According to recent observations of rural Pennsyl-
vania elderly (Guthrie et al., 1972), mean energy values

as compared to the 1974 RDA were 66 percent for men and

75 Percent for women. When Davidson and coworkers

(Davidson et al., 1962) expressed the daily caloric intakes

of their 130 older subjects on the basis of calories per

square meter body surface area, there was little difference

between the sexes, 1231 and 1174 for males and females,

respectively.

Two factors which contribute to the decline in
caloric requirements among the aged are (1) the decline

in basal oxygen consumption, and (2) the decrease in

physical activity. Regression analysis of the dietary

intake and physiological energy parameters of 252 middle

and upper class males aged from 20 to 99 years (McGandy

et al., 1966), suggests that daily caloric needs decline

by 12.4 calories/year, after the age of 20. A lesser por-

tion of this drop is attributed to the decrease in basal

metabolic rate (BMR),

specifically 5.23 calories/year,

 

 

er“. 4

44

whereas 7.8 calories are assigned to the reduced physical
expenditure of energy.

According to Keys (1952) basal energy needs
decrease by 5 percent each decade beyond the age of 50,
‘witli additional reductions for the changes in physical
activity; Therefore, older women may maintain their
health.and vigor with 1500 kcal or less, with older men

requiring 2000 kcal or less.

A committee on caloric requirements of the Food and
Agriculture Organization (FAO) postulated that the decre-
ment in energy requirement (Joint FAQ/WHO Committee, 1973)
was quite slow during the middle years, the earliest change
occurring about age 40. For this reason, caloric needs
decline by only 5 percent/decade between the ages of 40 and
59- From ages 60 to 69, the decrement equals 10 percent
each decade, and beyond age 70, a further decrease of

10 percent appeared to be justified.

Energy Expenditure

That physical activity may not decline significantly
in healthy elderly women was suggested by Durnin and
associates (1961, 1961a) who found their English subjects
to expend 1987 or 2100 kcal daily, depending upon their
family status (i.e., living alone or caring for a family).
Further evidence to suggest that physical activity may not
differ significantly between young and old individuals

comes from comparisons of men and women either 17-45 years

45

of age, or over 45 years (Durnin, 1966). Among both sexes
and age groups, activity was less in the "plump" as com-
pared with "normal weight" subjects. Although men over

45 years engaged in heavy exercise on only isolated
occasions, a larger proportion of the young men worked at
sedentary occupations. In respect to the female subjects,

no differences were noted between the age groups.

Basal Metabolic Rate

Many investigators have chosen to examine the
physical change occurring in total body basal metabolism
with advancing age. Shock (1955) evaluating all pertinent
data, concluded that the average values for basal calories/
unit surface area, fall significantly with age in both
sexes. Although the decrement is small when examined in
terms of individual differences, it remains statistically
significant when tested between the ages of 30 and 90.

Matson and Hitchcock (1934) reported that commonly
Emcepted prediction standards as Harris-Benedict or Aub—
DuBois, are not suitable for use with subjects over age
75, as these investigators observed their subjects to have
alower heat production than would have been predicted.
unmirming evidence comes from the work of Dalderup and
coworkers (1972) who concluded that age and height are less
important, and weight a more important determinant, in the
basal metabolism of older subjects. In this study,

mwsical activity, serum cholesterol level, or cardiac

:‘il

46

ischemia, did not contribute to the variance in basal
metabolic rates.

Benedict (1935), summarizing his findings with
several series of subjects, states that "the total twenty—
four hour heat production of women seventy—eight years of
age and over appears to be close to 1000 calories,
irrespective of weight or age." On the other hand, he
suggests that low heat production as found in some elderly
women does not necessarily indicate abnormality or lack of

vigor.

Thyroid Function

One possible explanation for the decline in basal
metabolism from youth to senescence is a change in thyroid
function. Kountz and others (1949), when measuring serum
protein-bound iodine and metabolic rate in 141 subjects
between 25 and 100 years of age, observed a gradual
decrease in organic iodide in males only; a finding corre—
lated with basal oxygen consumption. This relation between
organic iodide and basal metabolism in elderly males was
confirmed by Ackermann and Iversen (1953). According to
the latter workers, although the rate of thyroid uptake of
iodine is lower in the elderly, the total absorption is
actually greater, in that kidney removal of iodine from the
blood is slowed.

Gregerman and coworkers (1962) evaluating thyroxine

turnover in euthyroid men, concluded that the age-related

47

decrease in thyroid function is a homeostatic adjustment
necessitated by two factors; (1) a 50 percent decline in
the thyroxine degradation rate, and (2) a change in
thyroxine distribution Space, interpreted to relate to
decreased metabolic mass. A decrease in available thyroid
hormone would not seem to be a factor in the reduced

metabolic rate associated with advanced age.

Body Composition

A decrease in metabolic mass in later years, as
alluded to previously, or change in body composition, may
be involved with the observed difference in basal metabo-
lism. Studies by Shock and others (1963) confirm that
basal oxygen consumption when expressed per unit of total
body water or intracellular water, does not show a signi-
ficant regression with age. If loss of intracellular water
is indicative of the loss of functional cells, it would
suggest that oxygen consumption in those cells still
remaining, has not changed.

Because potassium (K) as an intracellular cation
is reported to remain constant in concentration, this
measurement is a method of choice for estimation of fat-
free metabolic mass. Relative to oxygen consumption, Allen
(1960) observed a positive correlation in young male
subjects of 314 kcal/day/K equivalent. Several investi-
gators (Forbes and Reina, 1970; Novak, 1972) by the method

of whole body counting demonstrated that total body K

48

decreases with age in both sexes. In addition, females

have less K/kg body wt at all ages, when compared with

males. Data from work of Novak (1972) indicates that in

males, loss of body K begins at age 20 and accelerates,

reaching a maximum between 65 and 85 years. Loss in females

was: first noted at age 30, and was seen to accelerate
betxveen ages 40 and 50, with relatively little loss there-

afteer. Longitudinal observations by Forbes and Reina

(19770) suggest that between ages 25 and 65, the average

male: loses 12 kilograms of lean body tissue, with the

average female losing five.
With the age-associated decline in lean body mass,

there occurs a corresponding rise in the percent of body

fat. Among urban Minnesotans (Keys, 1955), submitting to

body density determinations by underwater weighing, the
Percent of weight as body fat increased from age 25 to 55.
During that period, body fat as a percent of body weight
rOse from 14 to 25 percent in males, and from 26 to 38 per—
Cent in females.
Population studies in Michigan (Montoye et al.,

1965) and Czechoslovakia (Hejda, 1963) suggest that body

fat as measured by triceps and subscapular skinfolds,

increases until age 65 and then declines, particularly in
men. This might denote the earlier death of the fatter

individuals, or an actual loss of body fat in advanced

age. Montoye and coworkers (1965) conclude, however,

49

that those who do survive are more lean. Women at all ages

possess a higher percentage of body fat than do men.
Evidence suggests that aging in women is accom-

panied by not only an increase in skinfold thickness but
also a concomitant change in pattern of distribution.
Skerlj and coworkers (1953) upon examination of 84 women
fnonn 18 to 67 years, noted that while total body fat as
estimated by specific gravity continued to rise from
midrile to old age, subcutaneous fat and body weight did not.
Inasmuch as body weight remained the same, the authors
postulate that fat accrued by the female body in late
maturity is inner fat; this accumulation would appear to

occur in fat depots, or by organ infiltration, at the

expense of other tissues.

Findings by Young and others (1963) lend credence
to this suggestion, for among their subjects aged 30 to
50 years, skinfold and fat pad thicknesses accurately

reflected changes in percent of body weight as fat. From

age 50 to 70, however, total body fat increased by 32 per-

Cent; skinfold thicknesses did not change. At those ages,

130(1)] density was most highly correlated with abdominal

Circumference .

Similarly, Wessel and coworkers (1963) observed
marked gains in skinfold measures of the pubis, umbilicus,
scapula, and waist, in women 50-54 years of age, suggesting

fat deposition on the side, waist, and back. A comparison

of white and Negro subjects aged 50 to 70 years (Ohlson

50

et al., 1956) indicated that Negro women were more muscular
and less fat, possibly due to more strenuous physical work.
Further evidence to support a relation between

physical activity and body weight comes from other work

by Idessel et a1. (1966) who found a correlation coefficient

equalling -0.8 between degree of exercise and body weight,

in vvomen aged 20 to 69 years. Relating body fat to

finacztional response, absolute and relative weight and skin-
folri fat were lower in those women with higher rates of
cirtzulatory adjustment (i.e., lower oxygen uptake and
pulmmonary ventilation, following submaximal exercise).
Alternatively, examination of 62 older women (Brown and
Shephard, 1967) who as employees of a Toronto department
Store were physically active, revealed that 24 individuals
were obese, being 10-30 kilograms above their ideal weight.
Even in subjects of normal weight, the gradual

accumulation of body fat at the expense of lean body mass,

is a natural consequence of aging. Physically active

individuals, however, have less body fat than inactive

Subjects of similar age.

Protein Requirements

The traditional approach to the delineation of

Protein requirements for humans of all ages, has been the

balance technique. According to a recent evaluation

(Food and Nutrition Board, 1974) of the existing literature,

the minimum nitrogen loss (via urine, feces, sweat, hair,

51

sloughed skin, secretions, etc.) of a young, 70 kg man

consuming no protein is 3.7 grams each day. Such loss

would necessitate a daily protein intake of 0.45 grams/kg

body weight. Differences of opinion exist among various

:hrvestigators who consider the protein requirement of

older adults to be either greater or less than that of

young subjects .

Kountz and coworkers (1951), measuring nitrogen
balsance in four males aged 69-76 years over a six month
period, observed that diets containing less than 0.7 grams

pnatein/kg body wt/day resulted in excessive nitrogen loss

in all subjects. These authors concluded on the basis of

this study that an adequate protein allowance for older

adults equals 1.4 grams/kg body wt/day. In regard to the

Concept of protein-sparing (Kountz et al., 1955), 400
additional calories in the form of carbohydrate or fat
PrOduced in individuals receiving 1.0 grams protein/kg body
W’t/day, additional nitrogen retention equivalent to that
aflueved by an increase of 5 to 10 grams protein in an
iSocaloric regimen, suggesting that the initial caloric
intake was inadequate.

Conversely, high intakes of protein, above 1.5
grams/kg body wt/day, were poorly tolerated by elderly
fiufiects (Kountz et al., 1953) causing abdominal distention

and nausea, with marked increases in serum non-protein

rlitrogen levels. Plasma non-protein nitrogen in these four

52

individuals ingesting 1.5 grams/kg body wt daily equalled
36 to 45 mg/100 ml. These values are similar to those
observed by Addis and coworkers (1947) in young adults
ingesting equivalent levels of protein. Plasma proteins
diri not change. Daum and associates (1952) noted that daily
nitrrogen retentions on a series of regimens supplying from
1.2 to 1.6 grams protein/kg body wt/day, were slightly
lower in the older than in the younger subjects tested.
Other investigators (Roberts et al., 1948; Ohlson
et £11., 1952a), studying nitrogen retention in eight
women ranging in age from 52 to 74 years, concluded that an
average intake of 57 grams of protein daily was required
for equilibrium, although for individuals, the requirement
Varied from 34 to 94 grams. One—half of the women were in
balance at intakes of 0.71 to 0.75 grams/kg body wt,
although others needed from 0.81 to 1.31 grams. A statis-
tical relationship between intake and retention was
apparent only at those levels resulting in negative balance;
in the opposite circumstance, the absolute retention was
influenced by other factors. A period of loss was followed
by a period of retention if intake was sufficient; con-
versely, if previous intakes had stimulated retention,
fugher dietary protein would not increase retention, or in
Several instances, even decreased it. Among these subjects
0n self-selected diets, energy intakes less than 1800
calories daily were associated with nitrogen loss, rever-

Sible if total energy intake increased.

53

Compiled data from several studies of women in the
North Central region (Ohlson et al., 1952) suggests that
the protein requirement increases from ages 40—59, indica-
tive of the physical stress during this period. Estimation
of intake required for equilibrium rose from 66 grams at
ages 30-39 to nearly 70 grams at ages 40-59, with a decline
to 59 grams after age 70.

A factor not to be overlooked in the interpretation
of balance data is that protein requirements are conditioned
by previous intake, which in reference to the elderly,
involves the eating habits of a lifetime. Present evidence
would not support the conclusion that the protein require-

ments of older adults differ substantially from those of

Young adults whose growth is complete.

Arnino Acid Requirements

The amino acid requirements for elderly people have
nOt been defined as precisely as those for younger adults.
Attempts to determine these requirements have been made
by Tuttle and coworkers (1957) who found that when a diet
QCDnt‘aining the amino acids in the same ratio as in egg
protein was fed at a level to provide 7 grams of nitrogen
daily to men over 50 years of age, all subjects were in
IIegative nitrogen balance. The same diet, when fed to
r1Ormal young men, produced a state of nitrogen equilibrium.
These authors therefore concluded that the amino acid

requirements of older men are above the minimum levels

54

Previously determined to be adequate for nitrogen mainte-

nance in young men. The daily amino acid intake of older

subjects exceeded these established base levels. One

concern in relation to this work is the relatively short

experimental periods, as the balance studies were con-

ducted for only six days. Older subjects, especially,

may not adapt to a change in dietary pattern within this
Period of time.

Further study by these workers (Tuttle et al., 1959)

indicated that amino acid requirements of older people are

related to total calories and nitrogen. When energy intake

Was adequate to maintain weight, all subjects remained in

equilibrium on the amino acid mixture described. If total

nitrogen was doubled by the addition of glycine and

ammonium citrate, seven of the eight men were in negative

balance -

Watts and associates (1964) reported that the need

for individual essential amino acids among their male

subjeCtS aged 65 years or older was not increased above

that required for 25 year old males. Older males remained

in positive balance or equilibrium when ingesting 41 to
53 percent of the young adult requirement for methionine.
Amino acids were fed in the FAQ or milk pattern. This

finding is in contrast to that of Tuttle et a1. (1957) who

found that his older subjects could not remain in equili-

barium on intakes of less than 2.4 grams of methionine daily

 

55

as compared with the value of 1.10 grams, established as

adequate for young adults.

As to the quantitative intake of essential amino

aCids on a self-selected diet, evaluation of the food
intakes of 18 women ranging in age from 33 to 77 years

(Mertz et al., 1952) revealed that methionine was first

limiting, following by phenylalanine. In only 5 of 27

evaluation periods was the daily methionine intake equal

to or above Rose's suggested requirements for young adults.

The tryptophane requirement, defined by the plasma
response curve, was reported by Tontisirin and coworkers
(1973) to approximate two mg/kg body wt/day in elderly

SUbjects receiving protein equivalent to 0.5 grams/kg body
w13/6337. This level of nitrogen was previously observed to

maintain equilibrium in the four males and 10 females

tESted. The tryptophane value determined for younger

Subj ects using the same procedures equalled three mg/kg

130(1)! Wt/day. Those authors consider the decreased amino

acid need to reflect lowered protein metabolism and
diminished lean body mass in older individuals.
At the present time there is no conclusive

e"’idence to support the theory that amino acid requirements

are higher in aged adults. Hofstatter and associates

(1950) measuring plasma levels of amino acids in young and
old subjects of both sexes, found that older males had
lower concentrations of valine, leucine, and isoleucine,

Whereas tryptophane, lysine, and isoleucine were lower, and

56

histidine higher, in older females. These aged subjects,

hOwever, were hospitalized as a result of chronic disease.

The significance of these findings is unknown.

Effect of Anabolic Steroids

Some workers have attempted to induce nitrogen

retention in older patients of both sexes by use of
anabolic steroids, but results have been inconclusive.
Bew (1965) conducting a double blind trial of stanozolal
(an anabolic steroid) in 18 elderly females, noted a

Significant increase in body weight, which in the absence

of balance measurements, could reflect fluid retention

rather than protein anabolism. Watkin and coworkers

(1955) analyzing data from their series of balance studies
concluded that anabolic steroids (both estrogen and
testosterone derivatives) have no significant effect on
nitrogen balance in subjects already in positive balance.
If individuals on low protein diets were exhibiting
nitrOgen loss, steroids induced a positive effect, however,
less than that produced by a higher protein intake without

SterOid therapy. In light of numerous unpleasant side

effeCts resulting from steroid administration, it cannot be

routinely employed as a means of effecting positive nitrogen

balance in the elderly.
MProteins

Plasma protein, especially the level of albumin,

has been used as an index of over-all protein nutriture in

57

survey subjects. There is some disagreement as to the
changes in plasma protein levels that occur as individuals
age. One group of workers (Leto et al., 1970) found a
negative regression between serum albumin and age, in a
sample of 194 healthy males between 20 and 89 years of age.
Despite the lower serum protein levels among the elderly,
there were no other suggestions of protein deprivation.
There is a possibility that the lowered plasma
protein levels reported by Leto et a1. (1970) may have been
a reflection of an existing or previous disease state in
those individuals. This suggestion is based on the work of
VWDOdford—Williams and coworkers (1965) who have shown that
<3nly those elderly persons who suffered from chronic
<iiseases as osteo or rheumatoid arthritis or arterioscle-
1rosis, had hypoalbuminemia, with increased globulin con-
cIentrations. Older subjects with no obvious pathology have
£3erum protein values closely approximating young normals.
DeCosta and Moorhouse (1969) studying 43 individuals
1:‘anging in age from 73 to 87 years, detected no correlation
IDetween protein intake and serum albumin despite the fact
‘that several subjects had diets low in protein. Plasma
iprotein indices were within normal ranges. The precise
relation between dietary protein levels, plasma proteins,

and age, have yet to be defined.

58

\Htamin Requirements

On the basis of blood levels of a number of vita-
mins, it appears that older peOple metabolize these
nutrients in the same way as younger people. This sugges-
tion is based on nutritional status studies of older people
in San Mateo, California (Gillum et al., 1955a; Morgan et al.
et al., 1955); Groton Township, New York (Williams et al.,
1951); and Onondago County, New York (Brin et al., 1965).
Those surveys revealed no significant differences in serum
‘Values of vitamin A, carotene, and ascorbic acid, or in
‘lrinary excretion of thiamin and riboflavin, as a function
(Df age. When departures from accepted levels are observed,
tllaey can usually be related to inadequate intake of the

ITlltrient concerned. However, as pointed out by Exton-Smith

(IL968), biochemical variations in blood or urine which might
have little significance in the younger person, may, in old
Eige, when homeostatic mechanisms are often impaired or
Iinder pathological stress, be the first indication of frank
rmalnutrition. Deficiency states in the elderly, according
1:0 that author, are most likely to result from inadequate
lintakes of the B complex vitamins, ascorbic acid, and
‘Vitamin D. The requirements for these nutrients would not

appear to be elevated.

Eater-soluble Vitamins

Thiamin.-—Numerous studies have attempted to relate

thiamin needs to health and well-being in older individuals.

59

Studies with 220 human subjects between 40 and 102 years
of age by Kirk and Chieffi (Kirk and Chieffi, 1949; Chieffi
and Kirk, 1950) revealed a slight decrease in blood thiamin

with advancing age, whereas pyruvic acid levels did not

change. These institutionalized patients were receiving

diets presumed to be adequate in the vitamin. Clinical

evaluation indicated a higher frequency of symptoms

(i.e. general fatigue, tongue fissures, impaired vibratory

sense, edema, and tenderness of the lower extremities),

eumong those with blood thiamin levels below 2 ug percent.
UDon supplementation with thiamin hydrochloride, blood

leVels rose to normal, with concomitant alleviation of the

£3hysical signs. When treatment was discontinued, all

sYmptoms returned .

Rafsky and Newman (1943) noted that although all
of their institutionalized subjects between 63 and 89 years
c>fage who supposedly consumed an adequate diet exhibited
11<3rmal levels of urinary thiamin, 17 individuals required
It“Dre than one mg/day to produce tissue saturation.
ZXlternatively, no clinical signs were visible in eight

E“—‘lderly subjects (Wertz et al., 1941) whose measured daily

tLiaiamin intake ranged from 0.62 to 1.22 mg/day. These

‘Norkers discerned considerable variation from day to day
in thiamin excretion by the same individual, as well as

hBtween individuals on the same level of intake. This

finding was similar to that of Mickelsen et a1. (1946)

Who, studying thiamin metabolism in young males, concluded

60

that urinary excretion levels were an individual character-
istic with a lesser dependence upon dietary intake.

Many investigators have proposed a specific urinary
thiamin level as indicating dietary adequacy (Mickelsen
et al., 1947). On that basis, individuals excreting
reduced amounts of thiamin would be considered to be
deficient in intake. That low urinary thiamin levels among
older pe0ple do not always represent inadequate intake is
suggested by the work of Rafsky et a1. (1947). They found
low thiamin excretions among individuals consuming an
adequate amount of this vitamin. The reduced excretion
<20u1d not be explained on the basis of decreased stomach
acidity and consequent faulty absorption. Both low and
laigh measures of urinary thiamin were found in subjects
\Nith anacidity, hypochlorhydria, and hyperchlorhydria.
Roentgenological examination of patients with low thiamin
'excretion revealed no significant abnormalities (Maxwell
et al., 1952).

Several investigators have examined the relation
loetween thiamin need and advancing age using animal models.
‘An early study by Mills (1948) reported that thiamin
requirements in rats doubled with advancing age; no
similar change was observed for choline, pyridoxine, ribo—
flavin, or pantothenic acid. The basal ration fed in this
experiment, however, consisted of 76 percent sucrose,

possibly elevating the need for thiamin.

61

That any alteration in the thiamin requirement can-
not be attributed to differences in mechanisms of absorption
and phosphorylation is suggested by Draper (1958) who noted
that thiamin was efficiently absorbed (95% of test dose)
by rats up to the age of 20 months; beyond this time,

absorption declined to a level of 75 percent of the given

chose. Liver storage of esterified vitamin was lowered in

the older animals.

Riboflavin and Niacin.--Little information is
<avai1able regarding the riboflavin and niacin requirements

(Df the aged. Vinther-Paulsen (1952) investigating the

c><3currence of glossitis in 98 patients from 65 to 96 years

(Df age, discovered that 70 percent of the subjects failed

‘30 respond to supplementation with the B complex or

IDrewers' yeast. Clinical manifestations of poor thiamin,

1i‘iboflavin, niacin, and pyridoxine nutriture, in aged
Ibatients on a "supposedly good" diet, did respond to supple-
rnentation in a double blind study conducted by Taylor

(1968). Among those 80 subjects, symptoms of angular

Estomatitis, cheilosis, swollen red tongue, and "blotchy"

3red skin, disappeared following several months of supple-
Inentation with the B complex vitamins, only to return

Upon the discontinuation of this therapy.

Horwitt (1953) concluded from several thiamin and

riboflavin depletion-repletion studies with six older men

(mean age = 70.5 years) and five younger men (mean age

62

33.3 years), that under normal conditions, there is no

indication of increased requirements for vitamins among

older individuals. In the circumstance of low intake,

both experimental groups responded with decreased urinary

excretion; when the dietary vitamin was increased to RDA

levels, tissue stores were replenished.

Pyridoxine.—-For two other components of the B com-

 

plex, pyridoxine and vitamin B12, there is substantial

<EVidence that serum values may decline in healthy, well-

rnourished aged people. Ranke and coworkers (1960) esti-

"Lating plasma pyridoxalphosphate levels in terms of SGOT
activity, noted a marked difference between young and old

(linstitutionalized) subjects. Values in males dropped

from 16.5 units/ml to 13.0, whereas means for females

<2hanged even more from 18.8 units/m1 to 13.3. When the

Older men and women were given 250 ug of vitamin BG daily

:Et>r several weeks, stimulated levels of SGOT equalled those

11(3rma11y found in the young. The study was not continued

tx) ascertain if such induced levels are maintained.

Hamfelt's (1964) comparison of three groups; blood
ChDnors aged 20—29 and 30—59, and healthy volunteers over

E50 years, revealed a significantly lower plasma pyri-

<1Oxalphosphate value in the last group. Inadequate dietary

lintake was thought to be unlikely, although not measured.

Vitamin B12.--Evaluation of serum levels of vita-

r“in B12 in 324 subjects ranging from 10 to 89 years of age,

63

revealed that the serum vitamin decreased significantly
with advancing age (Chow et al., 1956a) . Gaffney et a1.
(1957) found a similar decrement in serum vitamin B12

levels among 528 apparently healthy males aged 12 to 94
years. Among subjects aged 20 to 49 years, less than 1
Pezrczent had serum levels of vitamin 812 below 100 ug per-
cent whereas 23 percent had values below 200 ug percent.
In comparison, in the subgroup aged 50 to 94 years, 18
percent exhibited serum levels below the 100 ug level with
74 percent below 200 ug. That diet per se is not solely
responsible for this change is suggested by evidence
Obtained from a sample of institutionalized subjects all of
whom were exposed to the same diet for at least five years.
When the serum values of these subjects were plotted in
relation to age, the regression line obtained was similar in
sloPe to that seen among the 528 males with varying diets.

In contrast, Waters and others (1971), in a ten-
year follow-up of 673 Welsh subjects, found that serum
Vitamin B12 concentrations rose in all age categories,
possibly as a result of a rise in living standards with an
increase in consumption of animal protein over the inter-
Vening period; however, the lowest values still existed in
the oldest age group.
Watkin et a1. (1953) conclude that tissue stores

of Vitamin B12 are lower in older subjects, in that 24—hour
eMcretion following intramuscular administration of a B

12
preParation is less than that seen in younger males.

64

These changes in excretion pattern could not be explained
merely by known differences in renal efficiency. Tissue
unsaturation may be a consequence of a defect in the
absorption mechanism of the vitamin (i.e. , lack of
intrinsic factor), as several laboratories (Chow et al.,
1956; Chernish et al., 1957) working independently, have
confirmed that absorption of vitamin B12 is significantly
increased when administered together with a preparation of
intrinsic factor.

Differences exist as to the therapeutic value of
this vitamin in the treatment of psychological and emotional
disorders arising in older patients. Hughes and coworkers
(197 0) observed that a B12 preparation had no greater
effe¢t than did a placebo upon the psychiatric state or
general well-being of 39 elderly patients who had low serum
Vitamin levels but no evidence of macrocytic anemia.
Similarly, supplementation produced a rapid rise in serum
levels in the 44 persons aged 81 to 99 years treated by
DaViS and associates (1965) . There was no evidence of
j‘mprovement in relation to weight gain, appetite, or sense
Of well-being.

Conversely, a double blind study of patients above
65 Years of age (Rafsky, 1954), all of whom had complained
previously of fatigue, revealed that 89 percent showed
clinioal improvement following injection of crude liver
preparations. Upon replacement of the supplement with

placebo, the symptoms returned. Mental confusion and

65

disorientation in elderly patients is usually assumed to
reflect cerebral atheroma, vitamin deficiency being recog-

nized only infrequently as the cause of the disturbance.

Folic Acid.--Lowered serum folate has, in older

people, been associated with macrocytic anemia. Hurdle and

Williams (1966) identified folic acid deficiency in 28 of

72 patients over 70 years of age, seeking admission to a

geriatric hospital. Degree of disability was significantly

related to serum folate levels.

(1967 )

Girdwood and coworkers
reported low serum folate in 8 percent of hospitalized
Elderfllgy'patients, whereas vitamin status among subjects of

equiva lent age living in their own homes, did not differ

from Young controls. Further evidence is derived from the

work of Meindok and Dvorsky (1970) who compared 59 elderly
persons residing in institutions and 51 subjects of similar
age living independently, with 100 young controls. These
workers found low levels of serum folate in 24.0 percent,
7'8 Percent, and 5.0 percent of the respective groups.
TheSe papers suggest that differences observed between

younger and older people in reference to folic acid status,

a .
re the result of low dietary folate, rather than increased

re - . . .
quirement or alteration in metabolism.

Ascorbic Acid.-—Ascorbic acid deficiency has long
been associated with clinical manifestations of skin
ertloJi‘rhages (senile purpura) and sublingual petechiae.

“asmuch as these signs are frequently observed among

66

older individuals, it has frequently been assumed, a priori,
that their requirement for ascorbic acid is increased.
Disselduff and Murphy (1968), among 20 hospital
patients between 68 and 97 years of age, found no relation
between low levels of leucocyte ascorbic acid and either
senile purpura or sublingual lesions. Half of their
patients were given from 50 to 1000 mg of vitamin C daily.

The other subjects received placebos. Two patients in each

group of ten, showed a disappearance of clinical signs

within two weeks.

Although older peOple frequently have petechial
hemorrhages or comparable lesions, these may not always be

the result of a Vitamin C deficiency. This is suggested

by the report (Andrews et al., 1969) that the sublingual
lesions observed at necropsy of 17 older people were

Presumably due to increased venous pressure. An ascorbic

acid deficiency was not the cause, since histological
examination revealed the presence of aneurysmal dilations

0f intact venules, with no sign of hemorrhage. Increased

VenOUS pressure rather than ascorbic acid deficiency, would

appear to have caused this degenerative change.
Morgan and others (Morgan et al., 1955) investi-

gated the vitamin status of 569 apparently healthy men and

w
Omen over 50 years of age. Women at all ages had higher

3
erum ascorbic acid than men, 1.07 compared with 0.83 mg

peI‘Qent. Males had higher dietary intakes on an absolute

67

basis; however, when intake was expressed in terms of body
Weight, the differences were not significant. Inasmuch as
serum vitamin was directly correlated with dietary intake,
Morgan suggests that the requirement of men over 50 years
of age may exceed that of women of similar age. No
changes in serum ascorbic acid with age were found among
other subjects ranging in age from 21 to 74 years
(Williams et al., 1951), although women had substantially
high er values, seeming to confirm the observations of
Morgan, Other investigators previously reported this sex
difference in serum ascorbic acid levels in young subjects.

According to studies by Kirk and Chieffi (1953) serum

ascorbic acid does decline in institutionalized men as a
function of age, with values for both sexes about one-half
thOSEE of young controls. Absorption would not appear to be
impaired, as supplementation by mouth of 100 mg of vitamin
daily demonstrated a marked rise in serum levels. Analysis
of hOSPital food by Eddy (1968) revealed that delay in
s":‘rVILng patients cooked potatoes and vegetables can result

m a loss of at least 75 percent of the ascorbic acid.

Fa”:‘Qoluble Vitamins

Ww-Of the fat soluble vitamins, vitamin A
metabolism was studied by Gillum et al. (19553) in the San
Mateo subjects described previously. Although a small age-
associated decline occurred in serum vitamin A and carotene.

the difference was not significant. Only 5.6 percent of

68

the sample had serum vitamin A below 30 ug percent, and

nearly one-half of the group had serum levels ranging

between 40 and 60 ug. Inasmuch as thickening of the bulbar

conjunctiva was identified in 94 percent of the partici-
pants, it would appear that this lesion is a consequence

of aging rather than vitamin A deficiency.

A similar conclusion was reached by Chieffi and

Kirk (1949) who examined 155 persons over 40 years of age.

Classical symptoms of vitamin A lack, as conjunctival

thickening, dry skin, and follicular hyperkeratosis, were

more frequent among those with low (1—15 ug/lOO ml) plasma

Vitamin levels than among those with higher levels. They
suggested that the effect of age on the structure of the
eye was considerably greater than that of nutrient level.
Yiengst and Shock (1949) offer evidence that
Vitalnin A absorption is not impaired, as administration of

100.000 LU. of the vitamin to 126 males between 40 and 80

years of age revealed no differences in maximum serum

levels. Subjects over the age of 70, however, required 6—8

hours to reach this value as compared with 3-4 hours

r - . .
equlred in the younger men. The return to fasting levels

w . .
as Slower in older than younger subjects. Whether these

di . . .
fferences would also occur upon administration of normal

i . . . .
etary levels of this Vitamin, 18 not known.

Vitamin D.--In view of the increasing incidence of

o
SteOporosis among the elderly, especially in females,

69

attention has been directed to the major nutrients involved

with bone calcification, including vitamin D. Although

laboratory methods exist for the determination of vitamin D

in blood, the procedure requires a fairly large sample and

has not been adequately evaluated. One study (Neer et al.,

1971 ) suggests that increased production of vitamin D by

exposure to ultraviolet light improves calcium absorption

in older people. These investigators, by balance technique,

found a significant increase in calcium retention among
those elderly males exposed to ultraviolet light for one
hour daily over a three month period. Controls of similar
age Wilo experienced no change in calcium absorption, were

not treated with the ultraviolet lamps, and in addition,

were not exposed to natural light. Further research to

defiriee the requirement for and effect of vitamin D supple-
mehtEitzion in elderly adults, especially as it relates to

bone disorders, is urgently needed.

Vitamin E.--Recent interest in the requirement for
Viteunin E has been generated by the increasing substitution

Of pclyunsaturated for more saturated fats in the diet.

Horwitt (1960) suggested that the need for alpha tocopherol
is directly related to the quantity of polyunsaturates or
Specifically, linoleic acid, ingested.

Dayton and coworkers (1965) studied vitamin E

me . . .
taJoolism in two groups of elderly men consuming diets

c
0“taining 40 percent fat. For the experimental group,

70

Polyunsaturates comprised two-fifths of the total fat; for
Controls only one-tenth. Although toc0pherol intake for
the experimental group did not equal recommended levels of
0.6 rug/gm unsaturated fat, no subject exhibited deficiency

signs. A later report by these investigators (Pearce and
Dayton, 1971) suggested that cancer mortality was increased
among those men receiving the diet high in polyunsaturated

fat-

Other workers have been concerned with serum levels
of tc><20pherol in relation to advancing age. In two popu-
latic>115 studied in which subjects ranged in age from 17 to
64 Years (Herting et al., 1965) , and 30 to 81 years

(Harris et al., 1961) , respectively, serum values of this

vitamin did not change. When subjects were supplemented

With vitamin E (McMasters et al., 1965) , the magnitude of
increase in blood levels was similar in all age groups.

In cC>r1trast, Chieffi and Kirk (1951) reported a tendency for
plasma tocopherol levels to rise with increasing age; this
was true for men but not women. Others found that among a
ranClem sample of patients over 25 years admitted to a
municipal hospital (Leevy et al., 1965) , low levels or

plasma tocopherol were not related to age or sex.
M'
l"\era_1§

Calcium.--Much attention has been directed toward
t . . . .
he requirement for calcium in older indiViduals. T1115

3 . .
tems from the fact that osteoporos15, resulting from loss

71

of one-third or more of the bone mineral, is one of the most

debilitating diseases of later life; furthermore, it carries
with it the increased probability of bone fracture. The
high incidence of this disease among women is emphasized by
Iskrant and Smith (1969) who found significant vertebral
atrophy in 80 percent of 2000 women examined in Detroit.
During the three years following that examination, occurrence

of bone fracture among these subjects, all over 65 years

of age, was directly related to the degree of bone

demineralization.

Bone Idineral Loss

Extensive evaluation by numerous scientists
would imply that the degree of bone lost in later years is
a C301‘Iflplex phenomenon, displaying interaction among physio—
logical, hormonal, racial, socioeconomic and dietary vari-
ables - That this demineralization of bone is not of recent
origin is supported by the study of prehistoric skeletons.
An anthropOIOgist (Perzigian, 1973) observed that age-
aSSOCiated bone loss characterized peoples in antiquity,
suggesting a basic metabolic phenomenon among all human
Speeies.

Garn (1972), summarizing aspects of accretion
and loss of cortical bone in over 13,000 subjects from
Seven countries, states that loss of cortical bone

egins by the fifth decade in both sexes, and over a period

0 .
f 50 years approximates in males and females respectively,

72

15 percent and 39 percent of total bone mineral. Relative

to bone dynamics, tubular bone adds to the subperiosteal

surface beginning in the fetal period and continuing

throughout life. At the endosteal surface, bone is lost

until the adolescent growth spurts; from that time on,

mineral continues to accrue through middle age. Beginning

at: age 40, the rate of osteoclastic activity exceeds
osteoblastic deposition with the consequent demineralization

of the skeleton. Garn concludes that skeletal bone in

old age is a function of the degree of skeletal develOpment

at maturity; however, the percent of total bone lost is

less in males than in females; in Negroes than in whites;

and in taller versus shorter individuals.

That dietary factors apart from those most directly
linked with bone formation may be associated with bone
structure was suggested by Morgan and coworkers (1962) .
They reported that among 719 women over 50 years of age,
bone: ciensity was directly correlated with serum levels of
Vita-Ruin A, carotene, ascorbic acid, and cholesterol.

Steroid hormones have been recognized as exerting

dls‘tinctive effects upon tubular bone (Garn, 1972) . The

outer bone surface is specifically responsive to testost—

“one, the inner bone surface to estrogen. With the decline

in gonadotropin in later life, the inner bone surface of

the older female undergoes considerable resortion, as

Similarly it gained in adolescence. Following menOpause,

bone loss accelerates. The estrogen effect is manifest

73

further as the endosteal apposition is significantly
enhanced during the first trimester of pregnancy. Alter—
nately, Smith (1967) suggests that metacarpal thickness
decreases more rapidly in women undergoing castration
men0pause.

In regard to the genetic influence upon bone
calcification, Smith and Rizek (1966) reported that Negro
women in southeastern Michigan suffered significantly less
age-associated loss of compact bone than did whites. Among
the latter, women of Anglo-Saxon ancestry appeared to be
particularly prone to vertebral atrOphy.

One explanation for the negative calcium balance
observed among older individuals is inadequate dietary
intake, coupled with obligatory urinary loss. A comparison
of dietary histories by Hayes and coworkers (1956) revealed
no differences in intake between 47 older subjects who
S“ffered fractures, and a similar group who did not;
howeVoer, twice as many women with fractures had protein
takes below the RDA. Further investigation regarding milk
drirlking habits in childhood, demonstrated that those
suf jEering fractures had consumed greater quantities of this
food. Further suggestion that dietary calcium has only a
minor effect upon mineralization of compact bone comes from
thQ work of Zeegelaar and associates (1967) who noted that

O O D I o
Ste0por051s .18 less common among natives of South America

74

where lifelong calcium intakes are less than 500 mg/day,
compared with United States citizens where the intake is
much greater.

The role of dietary calcium as a factor influencing
the development of osteOporosis is still unsettled. Part
of the problem arises from the fact that in many studies,
the supplementation of calcium was begun only after the
clinical signs of osteOporosis became evident. In one

such study, five osteOporotic patients were fed diets and
supplements which provided 800 to 1600 mg each day (Whedon,
195 9). These patients according to both x-rays of the
vertebral bones and clinical evaluation, showed considerable
improvement.

In contrast to these results is a study of 39

British women over 70 years of age (Exton-Smith et a1. ,
1966) . There were no differences between the women who had
lightly or densely calcified bone, as far as intakes of
calories, protein, calcium or vitamin D were concerned.

Low bone density was associated with low serum calcium-
phosphorus products.

A possible impairment in calcium absorption has
been prOposed in relation to bone fractures in later
1i f3. Draper (1964) noted that calcium absorption was
unimpaired in senescent rats, as these animals could

res‘pond to increased physiological demand for calcium by

75

increasing intestinal uptake. However, senescent animals
are also more susceptible to negative calcium balance as a
result of accelerated skeletal catabolism.

The importance of calcium absorption among older
people is in an equivocal state. On the basis of Garn's
(1972) suggestion, there is little possibility of over-
coming the osteoclastic process which inevitably should
lead to bone demineralization. There are a few reports

suggesting that a decrease in bone density may not
Imxzeassarily be an accompaniment of the aging process. One
of these is the study by Ohlson and coworkers (1952) who
noted that women 30 to 85 years of age (n = 136) remained
in calcium equilibrium over a wide range of intakes
provided they ingested at least 1500 kcal every day. From
the fourth through the eighth decade, the predicted calcium
requirements were 0.88, 0.87, 0.83, 0.92, and 0.73 grams/
day, respectively. Balance periods among these subjects
ranged from seven to ten days.

Conversely, Ackerman and Toro (1953; 1954) found
that eight men and an equal number of women, all ranging
from 48 to 80 years, required at least 0.79 and 0.66 grams
Of Qalcium/day, respectively, to remain in positive balance.
One male subject remained in negative calcium balance
deSpite an intake of two grams daily. One problem
encolmtered in all balance work is that of adaptation to

preVious intake. Among the 20 males studied by Malm (1958)

28 to 252 days were required for adaptation to reduced

76

intakes. Absorption studies with radioactive calcium
reveal no differences in absorption pattern or cumulative

excretion between osteoporotic females and age—matched

controls (Canniggia et al., 1965), although plasma 45Ca

levels one hour following administration were inversely

correlated with age.

The increasing use of food additives containing
pkuDSphorus has led to some concern as to a change in the
oaJLciumrphosphorus ratio in the American dietary. The
effect of varied calcium-phosphorus ratios upon bone
miriearal deposition and resorption has been explored in
animal models. Shah and coworkers (1967) reported that
ndr:ea fed a Ca:P ratio equalling 2:1 stored more bone than
those receiving a 1:1 ratio of minerals. Other authors
(Draper et al., 1972) suggest that a relative excess of
Phosphorus may depress intestinal calcium absorption and
inhibit.bone salt formation by creating a secondary hyper-
Paréitflnyroidism, with a depression of serum calcium.

Epidemiologic evidence suggest that lifelong intakes
Of ffluoride, in the drinking water of some communities,
retiirds age-associated bone loss. The ingestion of
fluQride at low levels enhances bone mineral crystallization
rerl'flering it less soluble and therefore less susceptible,

to Iresorption. Comparison of two populations over 45 years

Of iige in North Dakota (Bernstein et al., 1966) indicated

that fluoride intake significantly affected bone density in

77

women, although no such statistical association was detected
in men. Those women drinking water containing 4.0—5.8 ppm
fluoride had greater bone density and less evidence of
collapsed vertebrae than those whose water supply contained
0.15-0.30 ppm of this halogen. A similar study by Leone and
associates (Leone, et al., 1955) over a period of ten years
in Texas revealed that ingestion of water containing up to
eight ppm of this element produced no deleterious bone
changes. Rather, the authors conclude, the "fluoride
effect" may be beneficial upon adult bone. Although
fluoridated water, consumed over a fairly long span of the
individual's life, may have a beneficial effect on bone
mineralization, the ingestion of fluoride after osteOporosis
has become apparent, may not be beneficial. This is based
on the report by Cohn and coworkers (1971) . They observed
no Significant increase in total body calcium over a period

Of tWo to seven months of fluoride supplementation.

Lyle-According to a recent national survey
(U.S. - Department Health, Education and Welfare, 1972a)
approximately 10 percent of the women and 4 percent of the
men over 44 years of age had hemoglobin values below
12 gin/100 ml, which frequently is implied to be an iron-
deficiency anemia. If it is the latter, a primary cause
could relate to diminished absorption of the metal, coupled
With occult blood loss. From a theoretical standpoint,

there are a number of possible explanations for any

 

 

78

reduction in iron absorption among older pe0p1e. One of

these relates to achlorhydria which frequently develops in

older individuals. However, uptake of a supplement of

labelled iron was not lowered among achlorhydric patients

(Jacobs and Owen, 1969). These investigators found that

(absorption of inorganic iron was, on the other hand,
significantly less in subjects below 30 years of age than
111 persons over 50 years, however, no such difference
existed following administration of heme iron.

In contrast, Freiman and associates (1963) report
truest.healthy individuals aged 69 to 85 years absorbed
49—61 percent of ingested 59Fe administered under fasting
c011Ciitions. Young controls assimilated 71 percent of a
siuljmlar dose, although this difference was not significant.
Inasmuch as the percent of iron absorbed usually reflects
neeti ‘these values suggest existing iron deficiency anemia
among both young and old subjects, although hemoglobin

l(“’81s were within normal limits.

A less than adequate iron intake among older indi-

Viduals can be accentuated by occult blood loss. Observa-

tiOns in Goteborg (Hallberg and Hogdahl, 1971) confirmed

that anemia in women over 75 years of age, living inde—
pendently, was usually related to loss of blood in the
Stool. A review by Jacobs (1971) emphasizes that iron

deficiency anemia in the elderly subject signals an abnormal

CC’Ildition with underlying blood loss and pathology, rather

 

 

 

79

than increased physiological requirements. Balance
studies with 70 year old subjects (Finch, 1959) show that
physiological iron loss was approximately 0.6 mg daily as
compared with the value of one mg daily, established for
young males.

Among 340 subjects of both sexes aged 50 years or
older, the hematocrit and erythrocyte counts decreased
slightly with age, although not significantly so (Fowler
et al., 1941; Renbourn and Ellison, 1952; Shapleigh et al.,
1952) . Gillum and Morgan (1955) reveal that older males

had higher values for hemoglobin and packed cell volume
than older females. This is also true of younger men
versus younger women. A possible explanation for this
difference may exist in the quantities of food consumed by
men and women. The men in the California study (Gillum
and Morgan, 1955) ingested approximately 25 percent more
calol‘ies, protein and iron/kg body wt. The status of men,
as far as iron nutriture is concerned, is influenced by
their living conditions. This becomes apparent when it is
recanized that elderly males living alone (Robson and
Blackburn, 1953) have significantly lower hemoglobin levels
than men living with their spouses. Brewer et a1. (1956)
“(3th that institutionalized elderly displayed a greater
valriability in hemoglobin concentrations than is usually
found in younger populations. One possible explanation

mthlves the differences in the acceptance of various foods

80

by older age groups which may in turn reflect the response
of the individual to his (her) environment.
Factors Influencing Food Choices
of Older People

Daily food choices and consequent nutrient intake
are influenced by the interaction of multiple variables,
both internal and external in origin. There are probably
many factors which interact to influence an older indi-
vidual's choice of foods. Obviously, such choice is likely
to be severely restricted for those older individuals who
are institutionalized. For those who are not physically
confined, their food habits will be molded by physiological,
PSYchological, social and economic factors, as well as the
availability of different foods. To a certain extent, the
latter point has been ignored by Troll (1971) who suggests
that life in old age is much more a continuation of past
ways Of living than of marked change. In the United
States, there have been so many and such drastic changes in
agricultnire and food technology, that it is almost impossible
for elderly individuals to adhere completely to early
eating Euatterns. Relative to the eating practices of the
(elderly, the mere fact of their survival attests to some
degree of adequacy in this regard.

On.the other hand, aging is accompanied by change;
1:he aging body is increasingly sensitive to minor upsets;

the acCuStomed social pattern is disrupted; personal income

81

declines; physical activity is slowed. Consequently,
advancing age may bring changes in the customary food

pattern, with resultant differences in nutrient intake.

1393
Numerous investigators have observed differences in
nutrient intake between younger and older individuals. One
change, frequently reported, is a reduction in caloric
intake after the age of 55. This trend was noted among
Ibndon women living alone (Exton-Smith and Stanton, 1965),
780 Canadian subjects (Monagle, 1967), patients in Melbourne,
Australia (Saint et al., 1953), healthy elderly in Dublin
(Wilson and Nolan, 1970), and 2189 women in the North Central
states (Swanson et al., 1959). For the latter, mean in—
takes for many nutrients were definitely lower among those
70 Years and older than among subjects in their thirties.
DailY intake declined per decade by 85 kcalories, 4 grams
Emoteinw 30 mg calcium, 1.4 mg ascorbic acid, and 194 IU
Vitamin 13. The reduction in specific nutrients with
advancing years and the degree to which this occurs,
depends, to a certain extent, on the dietary practices of
the Older people. This was suggested by the higher intakes
Of calcium and riboflavin among 32 Nebraska women 75 or
Inore Years old (Fry et al., 1963). These women continued
to consume significant amounts of milk and milk products.
It was noted among the London women (Exton-Smith

and Stanton, 1965) that nutrient intake declined as a

82

result of changes in the quantity, rather than the kinds
of food consumed; nutrient density per thousand kcalories
did not decrease. The reduction in kcalories was brought
about primarily by a lowering of dietary protein and fat.
Further evidence for this trend is supplied by

Davidson and associates (1962) who noted that among 130
apparently healthy, aged subjects, the use of milk, eggs,
meat and fish, declined during adult life. In contrast to
these findings, a nutritional survey of families in Groton
Township, New York (Wilhelmy et al., 1950), revealed no
relationship between the intake of high protein foods and

the age of either husband or wife.

Physical Aspects

State of Dentition.—-One factor possibly associated

With changes in the food choices of older people might be
the increased incidence of oral lesions and loss of teeth.
In 81 Percent of 785 institutionalized elderly pe0ple
(BhaSkerg, 1968) with no subjective symptoms, there was soft
tissue pathology ranging from innocuous pigmentation to
early Squamous carcinoma. Problems with mastication were
reported among 70 patients over 65 years in Melbourne,
Australia (Saint et al., 1953) . Dietary intakes as a
Itesult‘thereof, were lowered among three individuals who

VVere edentulous, and 20 who were handicapped by ill—fitting

d enture s .

83

Alternatively, protein intake in gm/kg body wt, was
inversely correlated with chewing efficiency in the study
by Davidson et al. (1962); however, no relation was found
between nutrient intake and oral status. Evidence that
ability to chew may be involved with ascorbic acid nutriture
has been advanced by Exton-Smith and Stanton (1965). These
investigators describe two elderly subjects in London who,
having only few teeth and no dentures, avoided "hard or
tough foods" as fruits and vegetables. As would be anti—
cipated, both women had low intakes of ascorbic acid.
Further support for this hypothesis is provided by Morgan
and coworkers (1955) who reported that one—half of those
SUbjects with serum ascorbic acid levels below 0.5 mg/100 ml
were edentulous, as compared with one-third of those having
serum values above 1.1 mg/100 ml, although this difference
was not significant.

That dentition is not always the factor limiting
nutrient;in.take is indicated by studies in a number of
places in the United States. Healthy people in Groton
TownshiID' New York (Wilhelmy et al., 1950), and rural
PennSYIAIania (Guthrie et al., 1972), demonstrated no influ-
ence¢mf dentition upon nutrient intake; only six of 695
aged in Idnn County, Iowa (Fuller et al., 1963), reported
that dental difficulties interfered with eating. Among 100
older Subjects in Westchester County, New York (Jordan
et 511-: 1954), 65 rated their ability to chew as "good,"

11 as "fair," and 24 as "poor." with 75 0f the 9m“? wearing

84

dentures. Only four members of this sample related state
of dentition to a change in food habits. Similarly, a USDA
survey of older households (Le Bovit and Baker, 1965)
revealed that of subjects with poor, fair, and good diets,
5 percent, 6 percent, and 3 percent, respectively, reported

difficulty with chewing.

Sense of Taste.--Closely associated with dentition

 

and condition of the oral cavity is the sense of taste,
often thought to diminish in sensitivity with advancing
years. Nizel (1974) suggests that acuity of taste for
salt regresses, as a result of gradual nerve degeneration
and/or hyperkeratinization of the epithelium, with subse-
quent occlusion of taste bud ducts and pores. That
sensitivity to all four modalities: sweet, sour, salty,
and bitter, begins to decline after the age of 55, has
been reported by COOper and others (1959) from studies of
100 subjects from 15 to 89 years.

Glanville and coworkers (1964) observed that
threshold sensitivity to sour sensation decreased less
rapidly in females than in males. Henkin (1967) has
cmmMNTted that steroid hormones may play a role in the
normalmaintenance of the taste bud; however, the extent
Of this influence relative to taste loss in older people,

is not known.

85

Loss of Appetite.--Loss of taste among older
people has been suggested by some investigators as being
responsible for the reduced caloric intake among this age
group. Vinther-Paulsen (1952a) suggested that primary
disturbances of appetite regulation might lie in the
lessened secretion of digestive enzymes, along with changes
in endocrine function or psychological depression. Not
all older people are aware of any change in that 77 per-
cent of the 126 institutionalized elderly in Cherokee,
Iowa (Ginzberg and Brinegar, 1954), stated that their
appetite was good. Of the 16 percent reporting only fair
appetites, most objected to the particular kinds of food
they received. The 7 percent with poor appetites were
acutely ill and/or suffering from gastrointestinal dis-
orders. Of the people in Boston, who lived in their own
homes (Davidson et al., 1962) , most considered their
aPPEtihes to be good to excellent, although many thought of

eating as a necessity rather than a pleasure.

State of Health.--Since chronic diseases are

 

common among older people, those who are affected may be
11miteflx.in their dietary choices by the special diets to
WhiCh they are restricted. Such evidence is provided by
Taylor and coworkers (1971) , who, studying 216 elderly in
‘the United.Kingdom, found that vascular and epithelial
1935-0118 suggestive of vitamin deficiency and low intakes of

fruits and vegetables, were significantly more frequent

 

86

among those under treatment for chronic illness. State of
dentition was not recorded. This finding was supported by
other data obtained from Sheffield elderly (Bransby and
Osborne, 1953) who tended to reduce their intakes of cereals,
biscuits, fruits, vegetables and animal protein, as their
health deteriorated. Exton—Smith and Stanton (1965) con-
clude that although subjects with better than average

health consume better than average diets, it cannot be
assumed that health influences diet, as the reverse might
also be true. That therapeutic diets need not restrict
dietary intake is suggested by the USDA survey in Rochester,
New York (Le Bovit and Baker, 1965). Those individuals
requiring special diets were not consuming "poor" diets.

The reverse was true in that the percentage of subjects with
organic disturbances who chose poor, fair or good diets,

were 22 percent, 34 percent, and 30 percent, respectively.

§22£§£1§sychological Aspects

Social Isolation.--As indicated by Troll (1971),

 

food frequently fulfills social and psychological needs
relating to companionship, comfort, and sense of personal
and family well-being. By implication, this might mean that
SOCialisolationshould have an adverse effect on nutrient
.intake, Whether or not the transition from a family social
‘to a Solitary meal situation affects the intake of nutrients,

has been the subject of much consideration.

87

Davidson and coworkers (1962), in the study
described previously, reported that "socially isolated" men
and women had less variety in their meal pattern, with lower
mean daily intakes of all nutrients except iron. Similar
findings were reported for the elderly in Dublin (Wilson
and Nolan, 1970) where degree of social contact was signi-
ficantly related to nutrient intake. Those individuals
living with relatives had improved overall dietary intake

as compared with those who lived alone but obtained some

meals at a day center. The subjects who resided alone and

never shared meals, consumed less protein, iron and ascorbic

acid, with fewer calories.

A survey of 1771 English elderly (Bransby and
Osborne, 1953) over 60 years of age, revealed that men and
women living alone ate less of those foods requiring some
Preparation as potatoes, puddings, or sauces. In the
previously'cited Rochester study (Le Bovit and Baker, 1965)
single Women consumed as many calories as did those living
with their Spouses; however, the former had higher intakes
of carbcflnydrate, calcium and ascorbic acid, with less fat.
Conversely, Batata and coworkers (1967) , studying 100
patients in reference to iron, ascorbic acid, folic acid

and Vitamin B 2 nutriture, concluded that the old person

1
JLiVingalone was no more likely to be deficient than those

With comPanions .

88

§g§.--Further consideration of the nutritional
status of aged persons living alone does reveal striking
differences between males and females. That men are more
vulnerable to nutritional inadequacies, being less accustomed
to food preparation, has been shown by the Rochester data
(Le Bovit and Baker, 1965) in which men residing alone had
the highest percentage (39) of poor diets. Exton—Smith and
associates (1972) provide additional evidence, in that
solitary men over 75 years had a significantly higher
incidence of anemia, with low serum folate and ascorbic
acid. This might be related to the low consumption of
fruits and vegetables by older men living alone (Bransby

and Osborne, 1953)-

.Meal Pattern.--In that retirement places fewer

 

demands upon one's time, several studies have focused upon
meal Patterns of older individuals. For persons over 60
Years of age in Linn County, Iowa (Fuller et al., 1963):
the traditional three meal pattern was the favored choice
according; to 95 percent of those questioned. Fourteen per-
cent 0f t:hose living alone, consumed only two meals daily.
lRelative to cultural differences, surveys of the
aged in Westchester County, New York, (Jordan et al., 1954)
and New zealand (Davidson and Butler, 1971) , indicated that
about One-half of the respondents in each group have their
main meal at noon. Investigating sex differences, Lyons

and Trulson (1956) , studying Boston aged, report that

89

87 percent of the women as compared with 65 percent of the
men enjoyed three meals per day; the remainder chose to
have only two. Equal numbers of both sexes had one or more
snacks each day. According to Bransby and Osborne (1953)
"meals skipped" tend to increase with age, as records of
men over 75 years of age revealed that 12 percent did not
eat at noon, whereas 14 percent had no evening meal. This
finding might relate, in part, to lapse of memory among the

older subjects.

Food Faddism.--That food faddism may influence

 

nutrient intake in older people is suggested by the work of
Davidson and others (1962), who observed higher intakes of
protein (gm/kg body wt), vitamins A and C, thiamin and
riboflavin, among those indicating an interest in "health
foods." Mayer (1962) reviews this problem, citing that
older persons often function at a lower level of information
than the young; their isolation, sense of frustration, and
incurable chronic complaints, probably make them more
susceptible to the cures advertised by the food faddist.
Chinn (1956) reports that eight of 500 patients, seeking
hospital admission for long term illness, presented
definite psychiatric disturbances and had stopped eating.
Others with senile psychoses had developed paranoia

regarding the ingestion of "unsuitable" food.

Economic Status.--According to current census

statistics (U.S. Bureau of Census, 1971) about 4.5 million

 

90

or one-fourth of all older Americans live in households
with total incomes below the poverty threshold. Although
the aged comprise only 10 percent of the population, they
represent one-fifth of the nation's poor.

Income level and quality of the diet are frequently
related. Among Iowa women (Swanson et al., 1959) and
Groton Township families (Wilhelmy et al., 1950), protein
intake increased with the amount spent for food. For the
rural Pennsylvania elderly (Guthrie et al., 1972), dietary
protein, iron and riboflavin, were less in low income
families. Chope and Dray (1951) confirmed that serum
ascorbic acid was directly related to economic status, as
42 percent of the low economic group, 20 percent of the
middle income subjects, and none of the high income class,
demonstrated serum levels below 0.5 mg/100 ml. The money
value of home meals for Everett, Washington, families
(Van Syckle, 1957) ranged from 16 to 56 cents/person. When
this figure was less than 25 cents/meal, no household
attained 100 percent of the RDA for all nutrients. At a
cost of 24-44 cents/meal, nine households had "adequate"
supplies of nutritious food, although ten families did not.
Above this level of spending, all families had available
the recommended levels of nutrients. A generous supply of
calories does not guarantee that other nutrients will be
adequate as 6 of 16 families ingesting 135 percent of the
recommended kcalories were still low in calcium, ascorbic

acid, riboflavin, or a combination of these.

 

CHAPTER II

INFLUENCE OF PHYSIOLOGIC, SOCIOLOGIC AND

ECONOMIC FACTORS UPON NUTRIENT

INTAKE OF OLDER WOMEN

Introduction

 

Medical advances in the conquest of infectious
diseases have increased markedly the lifespan. In 1970,
the population of the United States included 20 million
persons above the age of 65. This number will have doubled
in 50 years (U.S. Bureau of Census, 1970).

Troll (1971) suggests that aging is accompanied by
change: the aging body is increasingly sensitive to minor
upsets; the accustomed social pattern is disrupted; per-
sonal income declines; and physical activity is slowed.

All of these factors may result in changes in the customary
food pattern, with subsequent alterations in nutrient
intake.

Swanson et a1. (1959) observed that intakes of
energy, protein, calcium, ascorbic acid, and vitamin A, were
significantly lower among Iowa women aged 70 years and
older as compared with those in their thirties. "Socially
isolated” aged Bostonians had less variety in their meal
pattern, with lower daily intakes of all nutrients except

iron, according to Davidson and coworkers (1962). In

91

 

 

92

contrast, a USDA survey of older households in Rochester,
New York (LeBovit and Baker, 1965), revealed that organic
diseases requiring special diets were not associated with
lowered nutrient intakes. Rather, the individuals who
followed modified dietary prescriptions had a higher per-
centage of good diets than did those not so restricted.

To ascertain the influence of social, psychological,
and economic factors upon the nutrient intake of older
women, the author re-examined the survivors of a sample of
103 women previously studied by Ohlson and associates in

1948. The women now range in age from 64 to 90 years.
Methods

Original Study

 

In 1948, Ohlson and associates initiated a study of
96 white women between the ages of 40 and 88 years, residing
in Lansing, Michigan. The subjects were chosen at random
by the following sampling procedure (Harper, 1956). All
blocks within the city limits (1185) were systematically
numbered and this figure divided by 100, the number of
subjects to be included. For the total of 100 interviews,
every twelfth block was visited. With the aid of the
Lansing City Directory, all residences in each block were
listed in order and assigned a number. The household
chosen for the first visit in each block was selected by
lot. If a woman above 40 years of age did not reside in

that dwelling, or if she could not or would not participate

93

in the study, the procedure was repeated until a subject
was secured. By this means 96 subjects began the program.
A ninety-seventh subject, a Lansing resident recommended by
one of the original sample, joined the study in 1950.

In 1948 and 1950, the women were interviewed by
trained personnel from the Department of Foods and
Nutrition, Michigan State University. Each subject
provided a one-day dietary recall in addition to a health
and nutritional history, and facts relating to marital and
socioeconomic status. All subjects were rated according to
a qualitative index for signs of aging. Forty-five of the
participants submitted to a physical examination given by
a mobile unit survey team from the U.S. Public Health
Service. This nutritional evaluation included the deter—
mination of hemoglobin values and fasting serum levels of
vitamin A, carotene, and ascorbic acid. A study of basal
metabolic rate was performed on 20 subjects, along with
rates of oxygen consumption in exercise and recovery.
Eighteen of the women c00perated in balance studies of
nitrogen, calcium, and phosphorus. These data have been
published (Ohlson et al., 1948; 1948a; 1950; 1952; 1952a).
A resurvey was completed in 1955 at which time a one-day
dietary recall record as well as current information
relating to socioeconomic, martial, and health status, was

obtained from 55 of the original subjects.

94

Present Study

 

Examination of all original records made possible
the identification of the 97 subjects who participated in
the nutrition survey in 1948, as well as six additional
subjects of similar age who had been recruited for metabolic
studies at that time. Inasmuch as food records were
available which indicated the nutrient intakes of the
metabolic subjects when on self-selected diets, these women
were included in the follow-up, making a total of 103
subjects.

Intensive search revealed 42 survivors of the
original group of 103 women. Three of these died there-
after, making a total of 60 subjects known to be deceased.
No information could be found regarding the current where-
abouts of four women in the original sample; however, none
of these could be located at the time of the resurvey in
1955. All known survivors were sent a letter of intro-
duction indicating plans for the present study (Appendix A-l).

Twenty-eight of the 39 survivors participated in
the 1972 study. Six of the 11 women who refused to
cooperate lived in Lansing, and five of these appeared to
be in good health. Reasons given for not wishing to
participate included working full-time, suspicions regarding
invasion of privacy, and not wishing to be bothered.

Three other women, living at some distance from Lansing or
out-of-state, were reached by letter, and for the two in

Michigan, by telephone as well, but would not c00perate.

95

Two of the survivors were being cared for in homes for the
aged; the families of these women objected strongly to any
visitation by the author.

The 28 subjects, ranging from 64 to 90 years, who
did agree to participate were interviewed by the author to
secure a 24-hour recall dietary record and nutritional
history (Appendix.A—2). In addition, information was sought
regarding the current marital, socioeconomic, and health
status of the subject. Food models were used to ascertain
the portion size of the foods consumed. To allow for
possible memory lapses, the women were asked to keep a
written dietary record for at least two days, given simple
instructions, and provided with a suitable record sheet
(Appendix A-3). The subject was visited the day following
the record-keeping, so that any questions regarding the
entries might be clarified. For the two cooperating sub—
jects who lived at some distance from the Lansing area, the
above information, as far as possible, was obtained by
telephone or through correspondence.

All food records were coded and nutrient values
calculated by computer using punched cards giving the
nutrient composition of foods according to household
measures (cards obtained from the U.S. Department of Agri-
culture, 1964; 1970). Additional cards were prepared as

needed for specific items not included in the USDA inventory.

96

The calculated dietary nutrient intakes and socio—
economic findings were evaluated statistically by analysis

of variance and correlation-regression methods.

Results
The living arrangements of the 28 participating
survivors are shown in Table II-l. The majority of the
women lived with their Spouses, whereas about one-fourth
resided alone. Two of the three subjects who lived with
an offspring were among the oldest subjects, aged 81 and 90
years. The third individual in this category, aged 75,

kept house for an unmarried son.

Table II-l.--Living Arrangements of Older Women Examined in

 

 

1972.
Percentage of Subjects
With spouse 57% (16)a
Alone 28% (8)
With son or daughter . 11% (3)
With another widow 4% (l)

 

aActual number of subjects.

Nutrient Intakes From Food

The mean nutrient intakes (excluding dietary supple-
ments) of the survey subjects are shown in Table II-2
(individual values may be found in Appendix A-4), The mean

caloric intake of the women was relatively low, equalling

1297 kl

with t

PL. -;\
ilk Y;

“n
x‘ b 16..
:n and
n: "D

C
\

Oi

I1
3:133:

due

Y)

fl
\u

; . T w u c . .1
C T. i 2% C C
1 l C a t .1 .0 .1
.3 Yr .1 Au Ll .wl
at v . .7. my, . P u}.

of th

.1 «Q
sh“ t
\flH A.V
«C 5.3

97

1297 kcalories, whereas mean values for all other nutrients,

with the exception of calcium, remained adequate in terms

Table II-2.--Mean Nutrient Intakes of Older Women Examined

 

 

in 1972.
Nutrient Mean Range

Calories (kc) 1297 606 - 2153
Protein (9) 59.2 29 - 81
Fat (9) 51.4 22 - 111
Saturated fatty acids (9) 17.6 4 - 52
Oleic acid (9) 17.9 5 - 44
Linoleic acid (9) 3.6 0 — 12
Carbohydrate (g) 151.3 54 - 275
Calcium (mg) 528 171 - 1144
Iron (mg) 10.1 6.2 - 17.4
Vitamin A (IU) 7969 1100 -37310
Thiamin (mg) 0.91 0.41 - 1.90
Riboflavin (mg) 1.45 0.66 - 3.57
\,, Niacin (mg) 12.7 6.7 - 21.0
93 12 - 200

As corbic acid (mg)

 

of the RDA (Recommended Dietary Allowances) for women of

this age.

Wide individual differences.

The ranges for the nutrient intakes indicate

Further analysis revealed that dietary levels of

the macronutrients--protein, fat, and carbohydrate, in

a"ici-ition to calcium, iron, and thiamin--were related to

to tal energy intake. On the other hand, intakes of

v j . .
tamin A, riboflavin, niacin, and ascorbic aCid, appeared

to A ,
be dependent upon the selection of specific foods.

Rib
Qflavin and niacin levels were correlated with dietary

pr ~
tein which contributed 18.5 percent of total calories

am
th these women. Biochemical indices of blood and urine

‘

98

(reported in Chapter V) were, in most cases, consistent

with the subjects' reported nutrient intakes.

Nutrient Intakes and the RDA

 

For the individual nutrients, variable percentages
of the subjects consumed at least one-half of that recom-
Inended (Table II-3). For energy intake, only 11 percent of
tlie Lansing women met the full allowance of 1800 kcalories,
:311ggested for women aged 55 and above. A more important
cakJservation might be that almost half of the subjects
consumed less than two-thirds of the RDA for energy; three
VVtDmnen ingested less than 1000 kcalories daily. Despite
this reduction in caloric intake, the majority of subjects
consumed the recommended level of protein; protein intake
e\. CiJr<quped to 29 grams only when caloric intake was rather low
(1009 kcalories) . The nutrient consumed in the lowest
E11h<>11nts was calcium, as 32 percent of those interviewed
we lreaIP'CDrted dietary levels below one-half the RDA (400 mg).
Vi tamin A and thiamin might be regarded as nutrients of
concern among older women, as 29 and 22 percent, respec—
tiVely, had only about half or less of the allowance.
When subjects were categorized according to their
da‘ ily intake of eight nutrients: protein, calcium, iron,
Vitamin A, thiamin, riboflavin, niacin, and ascorbic acid,

he
r1 of those interviewed in 1972 had consumed 80 percent

Ob
1b

more of the RDA for each of these nutrients. Six women

etched two-thirds of the RDA for all but one nutrient, and

 

‘

F
r
\

1‘4
niacif
:ael
;:1ti

\"

H
u‘r
be

.able '
.i.

q

‘1‘
«D

.I.

l/

99

Table II-3.--Percentage of Subjects Whose Nutrient Intakes

in 1972 Were Equal to, or a Fraction of, the

 

 

 

RDA.
. RDA Fraction
Nutrients

1a 2/3b 1/2C <1/2d

Calories 11% (3) 43% (12) 39% (11) 7% (2)
Protein 82% (23) 14% (4) 4% (l) 0% (0)
Calcium 11% (3) 46% (13) 11% (3) 32% (9)
.Ilrczn 57% (16) 36% (10) 7% (2) 0% (0)
Vitamin A 57% (16) 14% (4) 11% (3) 18% (5)
Thiamin 43% (12) 36% (10) 18% (5) 4% (1)8
Riboflavin 75% (21) 21% (6) 4% (1) 0% (0)
Niacin 57% (16) 36% (10) 7% (2) 0% (0)
Ascorbic Acid 79% (22) 7% (2) 7% (2) 7% (2)

—__¥

aThe dietary intake was greater than or equal to

tilléa 3.974 RDA (Food and Nutrition Board, Eighth Revised

Edition, 1974) .

b

JL The dietary intake was at least two-thirds but
ess than 100 percent of the 1974 RDA.

tail CThe dietary intake was at least one-half but less
an two-thirds of the 1974 RDA.

d
1974 RDA

eAs a result of rounding, the total percentage

3}:
i: ‘3 eds 100.

The dietary intake was less than one-half of the

rune fo'
L

dLets; c

b“.
in a
“g
\ ‘
:fl‘ ‘
H ];C
E
in

100

nine for all but two nutrients. Three women had poorer

diets; one consumed less than two-thirds the RDA for three
‘ nutrients, one for four nutrients; and the third, the

oldest subject, had less than two—thirds the recommended

intakes for calcium, thiamin, riboflavin, and vitamins A

and C.

Dietary Supplements

Among these women, 12 or 43 percent used some form

()1? dietary supplement with 10 doing so on the advice of
tiaeir physician. The types of supplements used, listed in
{Paikale II-4, included: multi-vitamin preparations with or
without iron, the most popular choice; B complex tablets
‘hrjstdn or without ascorbic acid; calcium; vitamin E; and
kazreevvers' yeast. These dietary additions, however, only

£>EiJ:t:ially and rather inadequately compensated for the major
r1111::rientdeficiencies in the diet, noted on Table II-3.
TWO wanen because of diverticulosis were advised to avoid
It‘éiljll’ fruits and vegetables, and consequently, ingested less
than half the RDA for vitamin A; on their physicians'
advice, they supplemented their diets with the B complex
and Vitamin E. On the other hand, many individuals with
rather good diets used supplements.
Ingestion of supplements as related to nutrient

jiltn.
-‘:;i5llie from food only, is illustrated in Figure II-l. Two
<>:tEF

‘tllle ten women who consumed 80 percent of the RDA for

Ilutrients, excluding calories, used supplements; this

3—

, g 4
M) )-‘y-.
..“_‘ '

a w

“ "P'vr i.
U V-HJIN‘D:
: 1"va _

tr;
8
U". h‘
4&e ‘iL
C.

101

Table II-4.—-Dietary Supplements Used by Older Women Examined in 1972.

Number of Subjects

 

‘ Number of Subjects Following Doctor's
Supplement Using Supplement Advice

Multi-vitamin capsule 2 2
Multi-vitamin + iron 4 3

B complex preparation 1 1
£3 complex + vitamin C l 1
VitmmIE l 1
Calcium salts 1 1
Calcium salts + vitamin D l l
Brewers' yeast 1 0
CFKDtal 12 10

 

Visas; also true for five of the six women whose intakes were
IL<3vv in only one nutrient. Half the subjects whose diets
“Vealree low in two nutrients, and one of the three having the
poorest diets used supplements. These additions improved
the nutrient intake as far as the RDA was concerned in only
E: iffiavv subjects. Among those women whose diets were low in
one nutrient, the supplement used restored only three of
't?;i“U'€3 nutrients to the RDA levels. Although half the
sub :1 ects low in two nutrients used supplements, in no case
Ci'ji“<il’ 1:hey restore those nutrients present in lowest amount

tQ
'tllae recommended level. The individual in the study with
1:1-1%
Ipoorest diet who was routinely supplemented, thereby

b3 :31
Sed her intake to acceptable levels.

3—

 

 

102

D/UAfi

5
7f’1

Figure II-1. Dietary Supplements and Total Nutrient
Intake.

Key:

m Number of subjects whose nutrient intakes from
food met the indicated fractions of the RDA.*

f

- Number of subjects in each group using dietary
supplements.

7 '

E:::] Number of subjects for whom the dietary
supplement raises the total intake (food +
supplement) to the indicated fraction of the A
RDA.

”01,155 I? 0’: SUBJE 6‘ 7'5
(1'!
I? '

 

*Food and Nutrition Board, 1974.

103

DIETARY WPPLEMENTS AND TOTAL NUTRIENT INTAKE

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2/3 RDA <2/3 RDA

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age b".

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104

Age and Nutrient Intake

 

- The 1972 dietary records were analyzed in relation
to age by decade interval (Table II-5). Although nutrient
values tended to decrease with age, these differences were
not statistically significant by analysis of variance.
Mean protein intake, however, differed by 14.7 grams, and
fat by 13.3 grams, between subjects aged 64 to 69 years and

those aged 80 to 90 years. By linear regression, protein
intake did decrease by 0.997 grams per year (r=-0.447,
n=28, p<.05) among these women aged 64 to 90 years. For

other nutrients, no predictive relationships were apparent.

Meal Pattern and Nutrient Intake
The various meal patterns characteristic of the
Lansing women are shown in Table II-6. Six or 21 percent
of the women ate only two meals per day, brunch in the
late morning, and dinner in late afternoon; whereas the
Others followed the traditional three meals per day
sCl'iedule. The majority of the subjects claimed they did
not eat between meals, the reason given most frequently
related to weight control. Eight women ate by themselves;
- Seven of these lived alone, and the other resided with an
unmarried son. Twenty or 71 percent of the subjects have
companionship at meals. An equal number of the women ate

. at
least one meal per week outside their home. Of the

‘

 

 

Table II-

==§

Nutrien

105

Table II-5.--Mean Nutrient Intakes of Older Women Examined

in 1972 According to Age.

 

 

Nutrient 64 - 69 70 - 79 80 — 90
(9)51 (10) (9)
Calories (kc) 1417 i 213b 1287 i 425 1189 i 248
Protein (g) 65.1 i 13.9 61.7 i 14.2 50.4 i 15.3
Fat (9) 57.0 i 11.9 53.3 i 25.6 43.7 i 14.3
Carbohydrate 162.3 i 36.5 140.0 i 57.4 152.9 i 36.4
(9)
Calcium (mg) ‘562 i 226 600 i 268 412 i 159
.IJCCDII (mg) 10.5 i 1.2 10.0 i 3.4 9.7 i 3.3
Vitamin A (IU) 7852 i 7041 6754 i 4690 9438 1 12266
Thiamin (mg) 0.89 i 0.11 0.96 i 0.42 0.88 i 0.33
Riboflavin (mg) 1.48 i 0.58 1.40 i 0.39 1.48 i 0.88
Niacin (mg) 12.3 i 2.3 13.0 i 4.4 12.8 i 4.6
Ascorbic acid 92 i 52 100 i 56 85 i 52
(InKQQ)
Pretein 18.4 i: 4.2 20.0 i 4.9 16.9 t 5.0
calories %
Fat calories % 36.1 i 6.4 36.2 i 7.4 32.2 i 6.3
CH0 calories % 45.6 i 6.4 44.0 i 7.9 51.3 i 7.6

\

3Number of subjects.

b

 

Values expressed as mean i

S.D.

Table II

Lats 'fl';
Léts CT.
1“ q
‘QL 16c

.-
t
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W
““E‘LQE
“(E "h

satin:

CRRA
”Rye,“ .

(”l
n3

V\eic

‘44Qlylld

106

Table II-6.--Meal Patterns of Older Women Examined in 1972.

Percentage of Subjects

 

Category
Two meals/day 21% (6)a
Three meals/day 79% (22)
Snacks between meals 39% (11)
Eats alone 29% (8)
Eats with companion 71% (20)
71% (20)

Eats outside the home
(at least once/week

aActual number of subjects.

eight subjects who usually ate alone in their homes, three
had at least one meal per week with family members in their
home or with friends at a restaurant. Although the 20
indixtiduals who reported eating outside their home
occasionally, had meals in other homes, the majority
visited restaurants either with their spouse or older
frienuas, frequently other widows. One woman reported that
she and her husband had their noon meal regularly at a
nearby fast food restaurant.

The meal pattern of the individual can influence
nuttrient intake. As shown in Table II-7, the subjects
eating alone consumed significantly fewer calories with a
concomitant significant decline in dietary protein, fat,
<2'J-‘i‘ic: acid, carbohydrate, niacin, and iron. Although the

individuals living and eating alone tended to be older

Variab

9

memes

‘2‘ ,A . J r
C .3 E. f\ S
a .... .h w.
.nu I) an 2.1
n» nu .. a 71)

l .2 3. C
6 Y4 no .3 6
file ea FL .u‘ Hid
h v v. a VA lflu

at (g)

)4,-
934.412)

107

Table II-7.--Relation of Meal Pattern, Nutrient Intake and Age Among
Older Women Examined in 1972.

 

 

 

 

 

 

 

 

Variable Eats Alone Eats With Companion Statistic
(8) (20)
Calories (kc) 1022 i 208 1407 i 287 F = 11.778**
Protein (9) 47.4 i 15.1 63.9 i 12.9 F = 8.560**
Fat (9) 36.9 i 11.6 57.2 i 18.1 F = 8.596**
01eic acid (9) 10.9 i 4.0 20.7 i 7.2 F = 12.955**
Carbohydrate (9) 122.9 i 36.4 162.7 i 42.9 F = 5.327*
Iron (mg) 7.9 i 1.5 11.2 i 3.1 F = 7.714**
Niacin (mg) 10.4 i 2.9 13.6 _+. 3.8 F = 4.571*
Age (yrs) 78.2 i 6.0 73.4 i 6.8 ns
Two Meals/Day Three Meals/Day Statistic
_ (6) (22)
Calories (kc) 1271 i 400 1304 i 302 ns
Fat (9) 61.5 i 28.8 48.6 i 14.8 ns
Protein (9) 51.7 i 13.6 61.2 i 15.3 ns
Calcium (mg) 372 :t 188 570 i 227 ns
Riboflavin (mg) 0.96 i 0.37 1.59 i 0.61 F = 5.829*
Ale (yrs) 77.5 i 8.5 74.0 i 6.4 ns
Snacks Does Not Snack Statistic
\ (11) (17)
Calories (kc) 1431 i 434 1211 i 178 ns
Fat (9) 62.5 i 23.6 44.2 i 10.2 = 8.085**
01eic acid (9) 21.2 i 10.3 14.5 i 4.6 F = 5.466*
Age (yrs) 74.7 i 7.9 74.8 i 6.3 ns
\

 

All values expressed as mean i S.D.
*p:.05.

**p§.01.

with a 1
£0: tho
signifi
subj at
daily;

74.0 ye
upon to
(6’36) a
Slied o
fewer m

108

with a mean age of 78.2 years as compared with 73.4 years
for those having a companion, this difference was not
significant. Neither did age relate to meal frequency, as
subjects with a mean age of 77.5 years had two meals
daily; whereas the individuals consuming three meals were
74.0 years in age. The number of meals daily had no effect
upon total energy intake, as the subjects with the lowest
(606) and second highest (1840) caloric levels both con-
sumed only two meals each day. In contrast, persons with
fewer meals each day ingested higher levels of fat, but
less protein, calcium, and riboflavin.

Eating between meals does seem to increase total
energy intake. The subjects who snacked had higher
dietary levels of kcalories, fat, and oleic acid. No

differences in age existed between those who did and did

not eat between meals.

.522£_j?lanning

When the subjects were asked, "What do you think
about; when Choosing foods for your meals?" (Table II-8).
'the “Host frequent response related to personal taste
preference (50 percent of those responding). Forty-three
percent of the subjects indicated that weight control was
a c30ncern, whereas 39 percent were motivated to produce
Well balanced meals. Four or 14 percent reported their
choice of food to be limited by financial considerations;

owewer, this restriction did not affect the nutrient

Table 11-

Ca

\

Fcods ":

Y , _ 1
3.0)) CQLC‘

'1‘

109

Table II-8.--Factors Considered in Meal Planning by Older
Women Examined in 1972.

 

 

Category Percentage of Subjectsa
Foods "1 like" 50% (14)b
Low calorie menus 43% (12)
Well balanced meals 39% (11)
Adherence to doctor's diet 29% (8)
"Nothing in particular" 29% (8)
Cost of food 14% (4)
Ease of preparation 11% (3)

 

aSubjects could indicate more than one factor.

bActual number of subjects.

content of their meals. The dietary quality of the women
whose choice of food was limited by financial considerations
is exemplified by their protein intakes which were 80, 78,
57, and 42 grams per day; that should be compared with

58.3 grams, the mean for the others. The woman whose

intake of protein equalled 42 grams consumed a total of

only 606 kcalories. Despite the cost of fresh produce,
dietary vitamin A and ascorbic acid levels among these
women were more than adequate. The subjects with financial

limitations tended to be slightly younger in age.

Shopping Problems

 

Six of the 28 Lansing women had problems obtaining

groceries; they relied upon neighbors or relatives to

drive 1

ORCQ e\

110

drive them to a store. Consequently, five shOpped only
once every two weeks. Twelve of the others visited a food
store once per week, whereas seven shop two to three times
weekly. One couple bought their groceries daily, seemingly
as a diversion; all individuals had facilities for storage
of refrigerated and frozen food. The women who were
unable to walk or drive to a store ranged in age from 66
to 83 years with a mean of 76.5 years, as compared with a
mean age of 74.3 years among those not so dependent. Two
of the subjects who required transportation cared for
infirm husbands, whereas four lived alone. No differences
in nutrient intake were observed between those who did or

did not require help with shopping.

Social Activity and Nutrient Intake

The Lansing women were rated as socially active or
inactive on the basis of their participation in an activity
outside the home (i.e., church, bridge club, senior citizens,
dinner with friends, etc.) at least once per week. On that
basis, 20 women were socially active whereas eight seldom
left their homes. Despite this difference in sociability,
there was no significant effect on the nutrient intakes of
the women, although the less socially active individuals
had an intake of 8.4 mg of iron per day versus 10.9 mg for
the others; that difference was not significant (p=.052).
Social activity would appear to be related to age, as those
women who remained at home were older with a mean age of

79.1 years, whereas the others averaged 73.0 years.

tagger
intak(

8530f.

111

Three subjects who appeared to be unaware of
happenings outside their home had substantially lower
intakes of protein, iron, the B complex vitamins, and
ascorbic acid, than did individuals who read a newspaper,
watched television, or were aware of current events. Two
of the three women with the poorest diets (less than two-
thirds of the RDA for three or more nutrients) were among
those with no external involvement. These women were older;
however, this difference was not significant.

Food Avoidance and
Nutrient Intake

 

 

The foods most frequently avoided by the Lansing
women are tabulated in Table II-9. Sixty-four percent (18)
of the subjects do not eat vegetables of the gas-forming
variety as cabbage or onions; the consumption of these
vegetables was reportedly responsible for considerable
distress. These subjects explained the omission of fats
and fried foods from their diets on the basis of the
abdominal distress experienced after eating these foods,
doctor's orders, or their desire to control their weight.
The latter reason was implied when 57 percent of the women
acknowledged avoiding "sweets" so as to reduce their
"energy" intake. Five subjects on physicians' orders had
to avoid pork and ham, because of fat and sodium restric-
tions. Other individuals (4) expressed a dislike of organ

meats. One woman restricted her meat to ground varieties

112

Table II-9.-—Foods Avoided by Older Women Examined in 1972.

 

 

Food Percentages of Subjectsa
Vegetablesb 64% (18)C
Fried foods 61% (17)
Fats 57% (16)
Sweets 57% (16)
Meat varieties 36% (10)
Nuts 29% (8)
Butter 25% (7)
Whole grains 18% (5)
Fruitsd 18% (5)
Milk 14% (4)

 

aSubjects could indicate more than one food.

bGas—forming or high in fiber content.

CActual number of subjects.

dAcidic or seed-containing.

only, because of ill-fitting dentures. Subjects being
treated for diverticulosis had to avoid all raw vegetables
and fruits, as well as whole grains. Milk was avoided by
four women primarily because of personal taste. No
subjects indicated abdominal distress resulting from milk
ingestion.

The avoidance of specific foods was categorized as
"high" when a woman rejected four or more foods and "low"
for those who avoided three or fewer foods (Table II-lO).
This difference in acceptance of foods influenced primarily

the caloric and fat intakes. Total fat as well as the

, .
(Alv‘
v. 'c
....d.E‘

R
v

uncle):
‘

F

a-
~-J

Y
Q
“ .
CELf

.11
(\
«U
ulna .
l—t ‘ut

113

Table II-10.--Relation of Physiologic Factors, Nutrient Intake and Age
Among Older Women Examined in 1972.

 

 

 

 

 

 

 

 

Variable High Food Avoidance Low Food Avoidance Statistic
(15)a (13)a
Calories (kc) 1177 : 264b 1436 i 326 F = 5.372*
Fat (9) 42.3 i 12.2 61.9 i 19.8 F = 10.274**
Saturated fatty
acids (9) 12.3 i 4.5 23.6 i 11.5 F = 12.335**
Linoleic acid
(9) 2.9 i 1.4 4.3 i 3.5 ns
Age (yrs) 75.5 i 5.8 73.9 i 8.1 ns
Prescribed Diet Self-Chosen Diet Statistic
(8) (20)
Fat (9) 42.6 i 12.5 54.9 i 19.9 ns
Linoleic acid
(9) 1.6 i 1.2 4.4 i 2.7 F = 7.534**
Ascorbic acid
(mg) 57 i 34 107 i 52 F = 6.467*
Age (yrs) 76.5 i 6.8 74.0 f 6.9 ns
Physically Active Physically Inactive Statistic
(15) (13)
Protein (9) 64.9 i 13.4 52.6 i 15.1 F = 5.172*
Iron (mg) 11.5 i 2.9 8.8 i 2.7 F = 6.543*
Age (yrs) 71.6 i 4.5 78.4 i 7.4 F = 8.804**

 

aActual number of subjects.

bAll values expressed as mean

*p:.05.

**p:.01.

i S.D.

dietary 1
were redx
DeSpite ‘
consume '

45001510

930393 8

114

dietary level of saturated fatty acids and linoleic acid
were reduced when four or more food items were avoided.
DeSpite the relatively high number of subjects who did not
consume particular fruits and vegetables, vitamin A and
ascorbic acid intakes were unaffected. The women in both

groups were similar in age.

Prescribed Diets and
Nutrient Intake

Of the eight Lansing women who followed a modified
dietary regimen, four had chronic diverticulosis, two
individuals were diabetic, one subject had a severe coronary
disorder, and another, myasthenia gravis. These women had
reduced dietary levels of linoleic acid and ascorbic acid
(Table II-10). Several of these subjects had been cautioned
in regard to the consumption of fried foods and acid
fruits; however, total fat intake nor age differed signi-
ficantly between those whose diets were restricted for

medical reasons and those whose diets were not so limited.

Physicial Activity and
Nutrient Intake

The degree of physical activity may influence food
intake in older women (Table II-lO). Subjects who parti-
cipated in bicycle riding (winters in Florida), gardening,
part-time employment, or hospital volunteer service, etc.,
consumed more protein and iron than did the sedentary
women. The restriction in physical activity of those
women, however, may have been associated with age since

that difference between the two groups was significant

e act

L
.3:

eafa

\
n
U

‘at

o n
tut

L
L 1

C

, E

.“

n-_&-v~
the 71

1.
sub."

..
we

{4“

lE'

115

(p=.01). Inasmuch as body weight did not differ between
the active and inactive women, obesity would not appear to

be a factor in determining physical activity.

Loss of Appetite

Relatively few of the Lansing women (8) reported
that they "feel hungry" whereas the others indicated that
they ate merely because it was the accustomed time. The
nutrient intakes of these groups did not differ; similarly
the mean age of those who "feel hungry" was 74.2 years

compared with 76.0 years among the women who experienced a

loss of appetite.

Discussion

Problems in Assessing Nutrient
Intake in Older Women

The collection and evaluation of food intake records
is fraught with difficulties. Questions arise as to
methodology, should 24-hour recall or written records be
collected, for how many days, and on which days. Moreover,
one may doubt the ability of the individual to accurately
estimate the amount of food he has consumed. With the
Lansing subjects, a 24-hour dietary recall record was
obtained initially; the women were then urged to keep
eritten records of their total food intake for a period of
cit least two days. Although individuals differed in their
degree of cooperation with the study, the majority of

guarticipants provided at least one written record. The

116

total number of food records available per subject ranged
from one to eight (Appendix C-2)-

Other investigators (Chalmers et al., 1952) have
been concerned with the number of daily records required to
adequately characterize the true nutrient intake of an
individual or a group. Analysis of dietary data obtained
from junior high, senior high, and college students;
pregnant women; and male industrial workers; revealed that
a dietary record consisting of only one day could effectively
estimate the nutrient intake of a pOpulation group. This
was true for all groups and nutrients evaluated. According
to those workers (Chalmers et al., 1952), however, charac-
terization of the dietary intake of an individual requires
extensive research (dietary records for a period of at
least 14 days) on that particular person. This evidence
would suggest that the Lansing results estimate the mean
dietary intake of women in this age group. Values obtained
for individuals would seem to be less reliable.

Many factors may influence the reliability of an
individual's dietary record. One of these factors would
appear to be one's sex. Indirect evidence obtained from
the population groups studied by Chalmers et a1. (1952)
revealed that precision from day to day tended to be
Sireater for women than for men. To estimate the mean

(Laloric intake of a male within 15 percent of the true value
reequired a dietary record of 14 days; a similar estimate for

a. women required a record of only 11 days. This could

refl ct
to crepe

the qu :

‘ a
"P A ‘f‘—
bunyl 4&4:
A. ”‘v‘r‘
a; linvvl
a

C1 .
K‘q'vln
C

‘¥1'\.

117

reflect a greater ability on the part of women accustomed
to preparing foods using household measures, to estimate
the quantity of food consumed.

Another factor relating to the reliability of a
dietary record is the constancy of the subject's food
pattern. Evidence that the constancy of the dietary pattern
is an individual characteristic comes from the work of Fry
et a1. (1963). After studying the normal daily variation
of dietary intake among six women who weighed their food
for periods ranging from 25 to 150 days, those workers
concluded that the particular pattern of the individual is
as important as the length of time they are observed.
Nutrient intake from day to day was remarkably constant in
three of the six women studied. For those Lansing women
following modified diets for the treatment of chronic
disease or in efforts toward weight control, the dietary
patterns tended to be monotonous, with the selection of the
same types and quantities of food each day.

Specific nutrients differ in their variability from
day to day in the diet records of an individual. Fry and
coworkers (1963) reported that vitamin A showed the
greatest variability in the dietary records obtained from
their midwestern subjects; in that study, thiamin, ribo-
LElavin, and ascorbic acid, also differed significantly
ifrom one day to another. Further evidence to support this
flinding of the differential variablility of particular

nthrients comes from the work of Chalmers et a1. (1952).

Vitamin
could n<
dietary
among t;
host V8
were v:
t0 the

769816:
these v
:0 Clay

4.“
(‘QJYS.

 

118

Vitamin A, ascorbic acid, riboflavin, and calcium intakes,
could not be accurately estimated for an individual unless
dietary records were compiled for several weeks. Similarly
among the Lansing subjects, the two nutrients showing the
most variability in the food records of particular subjects
were vitamin A and riboflavin. This finding usually related
to the consumption of liver or a dark green or yellow
vegetable or fruit, providing high levels of one or both of
these vitamins. Thiamin levels differed markedly from day
to day if pork or ham was consumed on one of the survey
days.

One might question the validity of recall dietary
records secured from older individuals who might be subject
to memory lapses. That this was not a problem in the
Lansing study is evident from the fact that the written
dietary records indicated essentially the same nutrient
intakes as the recall records. There was a difference in
caloric intake between recall and written records if the
written records included a Sunday meal; for many of these
women, Sunday dinner represented a special event. For that
reason, home interviews were not scheduled on Mondays.

That this difference in dietary habits between weekdays and
weekends is not a consistent trend among population groups
is suggested by Chalmers et a1. (1952). Those workers
concluded that college groups had lowered nutrient intakes

on Saturdays and Sundays, as did male industrial workers.

 

3:!

119

A final concern in the evaluation of dietary food
records is the ability of the subject to accurately
estimate his dietary intake. The Lansing women were
experienced in food preparation, and would therefore seem
to have a basis for judgment of household measures and
portion size. For items such as meat or cake, that cannot
be described in terms of liquid or solid measures, volume
was described by inch dimensions. Young et al. (1953) found
homemakers to be more accurate in their estimation of
nutrient intake than either college students or male
industrial workers. In that study calculated nutrient
intakes were, for two-thirds of the subjects, within 20 per-
cent of measured (weighed) intakes. Ohlson et a1. (1950)
studying the dietary intakes of aging women concluded that
a recall record was as acceptable as a seven-day weighed
intake record for estimating the nutrient intake of a group
consisting of at least 50 subjects. The Lansing study
included only 28 women; however, to the majority of these
individuals, the weighing of food would have been un-
acceptable.

A further problem in the analysis of food records
arises in the calculation of the nutrient composition by
use of food composition tables. Although such tables
attempt to provide representative values of specific
varieties of food items, the influence of the soil and
climate during the growing season, maturity at harvest, and

length and conditions of storage, can markedly influence

 

the not:
grain .
chemical

the Che:

Y .
LaHSLHg

male”

120

the nutrient content of fruits, vegetables, cereals, and
grains. Similarly, the feed given an animal may affect the
chemical composition of meat, eggs, or milk. Furthermore,
the chemical methods by which nutrient values were derived
may have been superseded by more accurate methods of analysis
since the publication of food tables now available. Despite
these limitations, the calculated nutrient intakes of the
Lansing women were evaluated in terms of the suggested

nutrient requirements for women of this age.

Nutrient Intake in Older Women

 

The most striking aspect of the dietary patterns of
the Lansing women was the relatively low energy intake,
averaging 1297 kcalories daily, with one as low as 606
kcalories. Exton-Smith and coworkers (1965; 1972), studying
two series of English women, found striking differences
in that 414 subjects above 65 years of age ingested an
average of 1711 kcalories daily, whereas others aged 70 to
80 years had intakes ranging from 1155 to 2930 kcalories
with a mean of 1890 kcalories. Among the latter, protein
provided only 12.1 percent of total calories, substantially
less than that noted among the Lansing women (18.5%).

On the other hand, Swanson and coworkers (1959),
summarizing data obtained from 1072 Iowa women, reported a
decrease of 85 kcalories per decade from age 30 to 80, with
a mean caloric intake of 1425 for those above 70 years.

Among the Lansing subjects, energy intake dropped by 130

kcalor:

kcalorj

121

kcalories from the seventh to the eighth decade, and by 98
kcalories during the eighth decade.

Alternatively, mean caloric intake equalled 1347 in
a study of 69 rural Pennsylvania women over 60 years of age
(Guthrie et al., 1972), a value approximately that observed
in the Lansing subjects. Similarly, Steinkamp and co-
workers (l965a) found a significant decrease in energy
intake from 1589 kcalories for females aged 64 to 69, to
1306 kcalories among those over 75 years of age. One of
the Lansing women reported an intake of 606 kcalories daily
in 1972; the energy value recorded for her in the 1948
survey equalled 745 kcalories. Since elderly women are
reportedly maintained in relatively good health on caloric
intakes that are about two-thirds the RDA, the true caloric
needs of this age group can be questioned.

Adequate protein intake is frequently a matter of
concern among older individuals. Protein intakes remained
high for the Lansing women despite diets low in calories,
which explains why protein contributed 18.5 percent of
total calories. Most subjects had at least two servings
per day of high quality protein; in many instances, meat
was consumed at both lunch and dinner, with an egg at
breakfast. The use of low-fat or skim milk contributed to
the pattern of increased protein with relatively low
calories and fat. The high levels of iron, riboflavin, and
niacin, reflect this generous protein intake. Liver was

consumed frequently (18% of the subjects) as were highly

fortifie
vitamins
used inf
of iron
collecte
and VQge
fiSCOIbi<
rePoke:

leafy a-

 

122

fortified cereal products, supplying iron and the B complex
vitamins. One subject, being treated for diverticulosis,
used infant cereal which in adult portions provides 10 mg
of iron per serving. Inasmuch as food records were
collected during the summer and early fall, fresh fruits
and vegetables added to the intakes of vitamin A and
ascorbic acid. Similarly, Pilcher and coworkers (1950)
reported a seasonal effect upon the consumption of green
leafy and deep yellow vegetables and fruits among the
residents of Groton Township, New York; substantially
larger amounts were available in the fall than in the
Spring. Among the Lansing women, locally grown acorn
squash and cantaloupe contributed greatly to vitamin A
intakes.

Milk and dairy products were not popular foods among
the Lansing women. Calcium was second only to calories in
the number of Lansing subjects whose intake was inadequate.
The majority of the women drank milk infrequently, con-
suming this product only with cereal; ice milk and cottage
cheese were used more frequently. Riboflavin was provided
in some cases by adding liver to the diet; however, dietary
calcium was not provided in substantial amounts by any
foods other than milk products. A USDA survey of the
North Central region (Redstrom, 1973) revealed the average
calcium intake among women aged 55 to 64 years to be 58 per-
cent of the RDA; this can be compared with the value of

66 percent observed in the Lansing women.

'Tv

thiamin
was it I

thiamin

this Wag
Vitamin
energy .
t0 that
rather .
inBikes
Wise Chc

Calorie:

123

Although one-fifth of those interviewed had low
thiamin intakes according to the RDA, in only one individual
was it less than 0.5 mg per 1000 kcalories. Reduced
thiamin levels may relate to the avoidance of pork as well
as the relatively low energy intakes. Ohlson and coworkers
(1952) in the 1948 study noted that protein, calcium, and
thiamin, were directly prOportional to kcalories ingested;
this was also true in 1972. In the former study, however,
vitamin A and riboflavin were also dependent upon the total
energy'intake. In 1972 these nutrient levels, in addition
to that of ascorbic acid, depended upon personal selection
rather than total kcalories. In view of decreasing energy
intakes in advanced age, sound nutrition is the result of
wise choices, with the elimination of those foods high in
calories and fat which provide few other nutrients.

The use of dietary supplements by the Lansing women
was similar to that observed by other investigators. Among
281 Californians over 50 years of age (Steinkamp et al.,
1965a), 35 percent took one or more food supplements with
the majority choosing a multi-vitamin preparation.
Similarly, 40 percent of the rural Pennsylvania elderly
(Guthrie et al., 1972) used vitamin or mineral additives,
With nearly one-half doing so on the advice of their
Physician. In that study only two subjects were supple-
mented with calcium although this nutrient was present at
less than two-thirds the recommended level in 66 percent of

the diets. A USDA study of older pe0p1e in Rochester, New

York (Le
the fax.
tainin;
This wa
the 12

dEfiCie

by Olie

124

York (Le Bovit and Baker, 1965), revealed that one-half of
the families using supplements were choosing foods con-
taining more than the standard levels for all nutrients.
This was also true among the Lansing women, as only 4 of
the 12 using supplements were actually correcting a dietary
deficiency. The misuse of vitamin and mineral supplements
by older individuals must be recognized as a growing
problem. For individuals who cannot, because of dietary
restriction, or will not, because of personal taste, eat
certain.foods, supplementation is a means of nutritional
support“ On the other hand, for those elderly with
financial limitations, available income might better be
spent for wholesome food.

The results of the Lansing study confirm other
reports that nutrient intake decreases as an individual
ages. Among 1,072 Iowa women, Swanson et a1. (1959)
observed a decrease in daily intake of 4 grams protein,

30 mg calcium, 194 IU vitamin A and 1.4 mg ascorbic acid,
per decade, between ages 30 and 80. Further evidence comes
fDmm.the Rochester survey (Le Bovit and Baker, 1965) where
a greater prOportion of the households with poorer diets
had homemakers over 75 years of age. Exton-Smith and
Stanton (1965), studying diets of elderly women living
alone, observed a substantial decrease from the mid to the
late seventies of 20 percent in kcalories, 30 percent in
fat, 24 percent in protein, and 8 percent in carbohydrate.

Inasmuch as calories supplied by foods rich in protein and

the die
3.7.339 t

f‘ B‘
V “L.

“.v-‘§_‘
‘ I
.‘.“\-4

"l'l§‘~; ‘

56...‘

125

fat are more likely to contribute minerals and vitamins to
the diet than do carbohydrate foods, the calcium intake
among those subjects fell by 18 percent and iron by 29 per—
cent. The Lansing women initially eliminated the less
nutritious foods from their diets and thus maintained their
vitamin and mineral intakes. A similar trend occurred
among the subjects studied by Fry and coworkers (1963).
They found that dietary calcium and riboflavin actually
increased in their women aged 75 to 85, as did the con-
sumption of milk. In the Lansing study, the older subjects
included liver in their diets and thus increased their
intakes of riboflavin and vitamin A. Of the nine subjects
80 years of age and above, one had 80 percent of the RDA
for all nutrients; three had two-thirds the RDA for all

nutrients but calcium; and one for all but vitamin A.

Socioeconomic Patterns and
Nutrition in Older Women

A frequent generalization with reference to the
nutrition of older people is that individuals living and
eating alone become bored with food preparation and conse-
quently resort to a monotonous fare. For the Lansing
‘nomen, dietary kcalories, macronutrients, iron, and niacin,
vvere significantly lower in those women who ate alone. Of
tzhe eight such individuals, five were 80 years of age or
anove as compared with 3 of 20 subjects who shared their

nuaals with someone. The energy intakes of the subjects

eating

126

eating alone was low, although the mean value was affected
by Subject 225, whose total intake was 606 kcalories.
Similarly, Davidson and coworkers (1962), comparing
the diets of "isolated" versus "socialized" Bostonians
over 50 years of age, noted that daily intake of all
nutrients except iron was lower in the "isolates." Although
in that study no person was grossly deficient in protein,
the only two individuals consuming less than 1.0 gram/kg
body wt/day were in the isolated group. Among the Lansing
women, four of five individuals consuming less than 100 per-
cent of the recommended level of protein lived alone; this
included the woman who consumed less than two-thirds of the
RDA. This lowered protein intake partially explained the
reduction in niacin among the individuals who ate alone,
whereas iron levels among these women were related to total
kcalories. In the Rochester study (Le Bovit and Baker,
1965) the diets of older women living alone contained lesser
amounts of meat, eggs, grain products, and potatoes, with
subsequent reduced iron intakes. It cannot be assumed,
.however, that older persons living with others are well
Imourished. This was evident from the diet records of the
tzwo Lansing women who had the poorest nutrient intakes.
TIhese individuals lived with relatives, but resisted all
eszorts of those in the household to improve the quality
of their diets. The food pattern of the oldest subject,
aged 90, who resided with a married son, consisted of meat,

99138, fish, potatoes and gravy, ice cream, cookies,

and bru

sugar.

no lon
their .
subjec

S‘Jr‘v’ey

127

and bread spread generously with butter and sprinkled with
sugar.

Meal patterns may change in older subjects who must
no longer maintain the time schedule previously imposed by
their occupation. Twenty-one percent of the Lansing
subjects chose to have only two meals daily, whereas a
survey of 14,991 aged individuals in Linn County, Iowa
(Fuller et al., 1963), revealed that only 5 percent
followed this pattern and none of those lived alone. The
latter survey included many farm families who may retain
their daily work patterns into advanced age. Inasmuch as
milk consumption closely paralleled cereal consumption,
intakes of riboflavin were significantly lower in those
having only two meals daily. The women who ate only two
meals preferred a heavier morning meal for which they
usually chose eggs, possibly with a breakfast meat, or a
sandwich with a meat filling; this could be a factor in the
higher intake of fat among those consuming only two meals.
The individual with the highest level of dietary protein
and fat was in this group which may also have influenced
'the mean fat intake of those who followed a two-meal
E>attern. As part of her evening meal, she consumed a nine-
ounce boneless steak with french fried potatoes.

A large percentage of older people supplement their

meaals with snacks. Among the Lansing women, 40 percent ate
bertween meals as compared with 50 percent of the older

Sulajects from Rochester, New York (Le Bovit and Baker,

1365), a
(Fuller
OflwrSt

Iowans,

128

1965), and one-third of the aged in Linn County, Iowa
(Fuller et al., 1963). Whereas cake, cookies, pie, and
other sweets were the most pOpular snack items among the
Iowans, the Rochester elderly and Lansing women more
frequently chose dairy products as ice cream or ice milk,
cereal with milk, or fruit, although cookies and candy
were noted occasionally. These dairy foods may have con-
tributed to the increased intakes of fat and oleic acid
among those who snacked.

Population studies (U.S. Bureau of Census, 1971)
suggest that at least one-fourth of all older Americans
live below the poverty line. It was surprising therefore
that only four of the 28 Lansing women interviewed con-
sidered their financial situation to be a limitation in
food selection. Some explanation may be found in the
geographic location of this study. In Lansing, the three
largest employers--Oldsmobile and related suppliers, State
government offices, and Michigan State University, all
provide pension benefits. Among those individuals who
were limited by income, protein intake was not lowered.
frhis finding is in contrast to the Iowa women (Swanson
eat al., 1959), Groton Township families (Wilhelmy et al.,
1.950), and rural Pennsylvania elderly (Guthrie et al.,
15372), whose protein intake was related to financial
reasources. Perhaps nutrient differences observed in other
Su.rveys among participants who expressed financial limita-

ticons, may have been a reflection of poor food choices.

129

This is suggested by the fact that two of the four women in
the Lansing study who stated that their dietary choices
were restricted for financial reasons consumed liver on one
of the survey days.

Physiologic Aspects of Food
Habitsgin Older Women

 

 

Physiological factors have been known to influence
nutrient intake among older people. The English women
studied by Exton-Smith and Stanton (1965) most frequently
avoided acid fruits or foods with small seeds, as a result
of diverticulosis or the subsequent develOpment of indi-
gestion; these reasons were given by several of the Lansing
women. Others in the English study indicated difficulties
with chewing, although this was noted by only one individual
in the Lansing survey and that related to meat choices.

Older individuals, according to Werner and Hambraeus
(1972), manifest a decrease in digestive enzymes. This
change could result in delayed fat digestion, leading to
prolonged discomfort. This may explain why 10 of the
Lansing women who complained of abdominal distress avoided
visable fat in their diets. This limitation on high-fat
foods may lower the intake of linoleic acid. Although the
suggested requirement for the essential fatty acid is
:2 percent of total calories (Food and Nutrition Board,
1974), nine of the 28 Lansing subjects consumed less than

that amount .

130

The dietary levels of other nutrients may be lowered
among older women following prescribed diets. Dietary
ascorbic acid levels were reduced among those individuals
who had been advised by their physicians to avoid acid
fruits; on the other hand, intakes of riboflavin and calcium
were high as a result of the selection of milk and/or liver.
Two women being treated for diverticulosis had less than
2000 IU of vitamin A daily, and for one, ascorbic acid fell
below 30 mg daily. Although orange juice, a generous source
of ascorbic acid, does not contain seeds, diverticulosis
patients were restricted to non-acid juices and fruits.
Inasmuch as 20 percent of all individuals over 70 years of
age have diverticular disease (Painter and Burkett, 1971),
the nutritional status of those following modified diets
prescribed in treatment of this disease, requires further
study.

Physical activity may not always decline as a result
of advancing age. Such evidence comes from the study of
the aged pOpulation in Westchester County, New York (Jordan
et al., 1954), in which only 30 percent of the subjects
Ivere described as sedentary whereas 67 percent were
nuoderately active. Although the Lansing women were about
exaenly divided on the basis of physical activity, that
dijision appeared to be related to age. In that protein
iJltake decreased in the older subjects, this might eXplain
‘thce lower level of that dietary ingredient among the in-

aCtive .

fr»

associat
13 women
than 80

their in
an 8Xpla

hemOgloh

weight.
the Othe

fol thei

131

A reduced level of physical activity is sometimes
associated with iron-deficiency anemia. Since seven of the
13 women considered to be inactive had iron intakes less
than 80 percent of the RDA, it might be postulated that
their inactivity was related to incidence of anemia. Such
an explanation is Open to question in that the lowest
hemoglobin level observed among the subjects with reduced
iron intakes was 12.6 g/100 ml. Among the Lansing subjects,
the degree of physical activity was not related to body
weight. Three of the sedentary women were obese, whereas
the others were either underweight or near average weight

for their height and age.

Conclusions
Although the intake of energy along with other
nutrients, declines with advancing age, this does not
necessarily result in poor nutrition. The selection of
foods high in nutrient density as skim milk fortified with
protein solids and vitamin A, or liver, may contribute to
the maintenance of nutritional adequacy. When inadequate
dietary intakes are observed among older women, deficiencies
are most likely to occur in the levels of calories, calcium,
Vitamin A, and thiamin. In light of the decrease in
PhYSical activity and problems with weight control that
occur in later life, the current recommended level of 1800
kca:Lories daily for women aged 55 and above, may have to be

r ~ 0
e eXaml ned .

older p

.
ments 0

meetin

needles

limitat
(1139036

fiV' ' q

132

The misuse of vitamin and mineral supplements by
older people is a growing problem, as frequently the supple-
ments do not include the most deficient dietary nutrients.
Conversely, many individuals with optimum nutrient intakes,
meeting known dietary standards, ingest supplements
needlessly;

Socioeconomic factors as social isolation, economic
limitations, or problems with shopping, do not always pre-
dispose the individual to a nutritionally poor diet.
Physiologic factors, however, as modified diets required
in the therapy of chronic disease, may impose restrictions
on foods that are Specific vitamin sources (i.e., vitamin A
or ascorbic acid). Supplementation of these diets with the
apprOpriate vitamins may provide a solution to this problem.
The avoidance of dietary fat as a result of abdominal dis—
comfort, efforts toward weight control, or a modified diet,

limits in this age group, the intake of linoleic acid.

CHAPTER III

NUTRIENT INTAKE IN 1948 AND SUBSEQUENT

MORBIDITY AND MORTALITY

Introduction

 

Life expectancy at birth has, during this century,
increased from 48.7 to 74.9 years for women and from 48.2
to 67.4 years for men. This increase in longevity has
resulted in a rapid growth in numbers of persons in older
age groups. In 1970, there were in the United States, 8.4
million males and 11.4 million females over 65 years of age.
Should the rates of mortality for both sexes remain con-
stant, in 50 years, the number of people above this age
will have doubled (U.S. Bureau of Census, 1970).

With these changes in population, the emphasis in
heaJIJI care has been directed toward the burgeoning problems
0f chronic disease, which is so common among older people.

Epidemiological evidence (Epstein et al., 1965) suggests
that 73 percent of those aged 60 to 79 years suffer from
at least one chronic problem (i.e., coronary or hyperten—
Sive heart disease, diabetes, respiratory disease or

r . . . . . .
helilmatOid arthritis). Chronic disease may contribute to

133

physic
have 5

cent t

134

physical disability in that 42 percent of aged individuals
have some limitation of activity, and for another 37 per-
cent the impairment is major (Metropolitan Life Insurance
Company, 1974). Acute disablement frequently necessitates
institutionalization of the older citizen; of the 995,000
individuals (U.S. Bureau of Census, 1973, p. 44) now being
cared for by this means, nearly two-thirds are women.
Inasmuch as the lifespan of women has been increasing con—
sistently, whereas that of men has remained stationary,
Howell and Loeb (1969) suggest that "the most seriously
needed type of study in America is to find through long
periods of time, the degree of correlation that exists
between the health records of individuals and their dietary
habits."

Studies in the United States examining total dietary
intake in relation to morbidity and mortality have been
limited. A four year follow-up of 577 Californians (ChOpe,
1954) over 50 years of age, revealed higher rates of
mortality associated with lowered intake of vitamin A,
niacfiJi and ascorbic acid. Furthermore, Chope (1954)

reported that subjects with hemoglobin levels below

13 gm/loo ml suffered a higher incidence of respiratory
disease, whereas daily vitamin A intakes below 5000 IU
Wer e Correlated with nervous, circulatory and respiratory
disorders. When dietary thiamin was low, diseases of the
nerVOUS and circulatory systems increased; conversely,

Iii. . . . . .
c31131-r1't'.a..kes of ascorbic aCid were assoc1ated with low

 

inciden

examinr

mtfie:
CauSe C
EXPEIiE

Kelle;

Signs C

\
'o.
*4

135

incidences of these problems. Kelley and coworkers (1957),
examining a random sample of 97 Michigan women between the
ages of 40 and 88 years, noted that physical well-being was
directly related to nutrient intake. Physical complaints
as pains in the joints or unexplained tiredness were more
frequent among those with diets low in one or more nutrients.
Mortality over a seven year period was higher in those
women reporting less than 40 percent of the Recommended
Dietary Allowance (RDA) for at least one nutrient.

To obtain further knowledge regarding the effect of
nutrient intake upon morbidity, length of life and ultimate
cause of death, the author examined the continued mortality

experience of the Michigan women, previously studied by

Kelley and associates (1957).

Methods
Between 1948 and 1955, Ohlson and coworkers (1948,
1950, 1952, 1952a) conducted studies with 103 white women
between the ages of 40 and 88 years, residing in Lansing,
Michigan. The sampling procedure and methods have been
described previously (Chapter, II, pp. 92-93). Each
subject provided a dietary recall record for at least one
day in addition to a health and nutritional history, and
facts related to marital and socioeconomic status. All
su13'fiects were rated according to a qualitative index of
Signs Of aging. Forty-five of the participants submitted

't . . . . . .
o a PhySical examination given by a mobile unit survey

team f

evalua

Categc

136

team from the U.S. Public Health Service. This nutritional
evaluation included the determination of hemoglobin values
and fasting serum levels of vitamin A, carotene and ascorbic
acid.

Sixty of the original subjects are now deceased and
death certificates (Appendix B-l) were secured from the
State Department of Vital Records. Causes of death were
categorized according to the International Classification
of Diseases, Adapted for use in the United States (U.S.
Department of Health, Education and Welfare, 1967).

To maximize the examination of all available data, factors
contributing to death and previously recognized chronic
diseases noted on the certificates, were also tabulated.
Analysis of variance, student's t, and step-wise deletion
multiple regression procedures were employed to seek
relationships between nutrient intake, physical and bio-
chemical parameters, chronic disease and mortality eXperi-
ence. (Subjects' ages in 1948 and at time of death may be
found in.Appendix B-2).
39.21.12
Merit Intakes of Deceased
Ed Surfivors in 1948
The dietary intakes of the deceased and surviving
subjects when both were examined in 1948 are listed in
Table III-l. The nutrient levels at that time were similar,

vv‘ . . . .
1th the exception of protein and ascorbic aCid. These

f . . . . .
aCtors were Significantly lower in the diets of those

 

Table I

137

Table III-l.--Comparison of Nutrient Intakes of Subjects in

 

 

 

1948.

Nutrient Deceaseda Survivors
Calories (kc) 1580 i 394 1683 i 632
protein (g) 50.8 i 14.2c 58.4 : 17.9C
Fat (9) 72.9 i 22.1 73.9 i 32.8
Carbohydrate (9) 180.5 i 53.0 196.5 i 78.2
Calcium (mg) 478 t 247 491 i 284
Iron (mg) 9.4 i 2.3 10.2 i 5.1
Vitamin A (IU) 4214 i 4408 3866 i 3728
Thiamin (mg) 0.86 1 0.24 0.95 i 0.53
Riboflavin (mg) 1.11 t 0 45 1.19 i 0.54
Niacin (mg) 8.4 i 3.5 9.0 t 2.3
Ascorbic acid (mg) 51 i 40d 73 i 40
Protein calorie % 13.1 i 3.4 14.4 i 3.4
Fat calorie % 41.3 i 6.4 38.6 i 6.5
Carbohydrate calorie % 45.5 i 7.1 47.0 i 6.3

an=60. These women died during or prior to 1972.
bn=28. These women were interviewed in 1948 and

1972; dietary records used in this calculation were those
Secured in 1948.

Ct=2.14o, p<.05.

dt=2.360, p<.05.

‘Values expressed as mean : S.D.

ILetter pairs are significantly different.

 

women (
intake
consume

differ<

138

women who have Since died. This difference in protein
intake has been examined in relation to the type of protein
consumed. As Shown in Table III-2, the quantitative
differences in total protein intake can be explained solely
by the increased consumption of animal protein by the
survivors. The mean intake of plant protein (20.4 grams)
was the same for both groups. Animal protein, however,
equalled 38.0 grams among the survivors, compared with

30.4 grams for the deceased, a Significant difference.
Therefore, only 57.7 percent of the total protein intake was
supplied by animal sources among the deceased, in contrast
to 64.4 percent for the survivors.

Age may be an important factor in evaluating the
differences between these two groups. In 1948, the average
age of the subjects who were re-examined in 1972 was less
than those who died in or prior to 1972. The mean age of
the deceased was 67.4 years, Significantly higher than that
0f the survivors who averaged 52.1 years (t=7.309, p<.01,
l-tailed test).

Kelley et al. (1957) observed higher mortality over

a Sevencyear period among those individuals who consumed
less than 40 percent of the RDA for at least one nutrient.
The 1948 dietaries have been evaluated in these terms.
Table III-3 indicates that no subject in either group con-
smed less than 40 percent of the RDA for calories,
protein, iron or thiamin. Similarly, it would seem that

C .
alelum intake did not influence the mortality rate of

Table

and 19
those

139

Table III—2.--Differences in Dietary Levels of Plant and
Animal Protein of Older Women in 1948.

 

 

Nutrient Deceaseda Survivorsb
Total protein (9) 50.8 r 14.2C 58.4 r 17.9c
Plant protein (g) 20.4 i 6.4 20.4 r 9.6
Animal protein (g) 30.4 + 14.0d 38.0 r 15.3d
% protein--plant 42.2 r 14.88 35.6 r 13.4e
% protein-~animal 57.7 r 14.7f 64.4 r 13.4f

 

an=60. These women died during or prior to 1972.

bn=28. These women were interviewed in both 1948
airxi 1972; dietary records used in this calculation were
those secured in 1948.

Ct=2.14o, p<.05.

dt=2.316, p<.05.

et=2.012, p=.05.

ft=2.029, p=.05.

Letter pairs are Significantly different.

Values are expressed as mean i S.D.

140

Table III-3.--Percent of Subjects Ingesting Less Than
40 Percent of the RDA* For Various Nutrients

 

 

in 1948.

Nutrient Deceaseda Survivors
Calories 0 0
Protein 0 0
Calcium 28% (17) 36% (10)
Iron 0 0
\Zitamin A 33% (20) 28% (8)
Ifliiamin 0 0
Riboflavin 5% (3) 4% (l)
Niacin 7% (4) 0
Ascorbic acid 32% (19)C 7% (2)°

 

*Food and Nutrition Board, Recommended Dietary

Al lowances , 1953 .

an=60. These subjects died during or prior to 1972.

bn=28. These subjects were interviewed in 1948 and
1972; dietary records used in this calculation were those

Secured in 1948 .
CLetter pair is Significantly different, X =5.336,

£><I-()5,

141

these women, in that 36 percent of the survivors and 28 per-

cent of the deceased had less than 320 mg daily, whereas

the recommended level was 800 mg. Although low intakes of

riboflavin, niacin and vitamin A, were noted more frequently
among the deceased, these differences were not significant.
Alternatively, a significant number of the deceased subjects

had less than 40 percent of the RDA for ascorbic acid.

Biochemical Indices Of Deceased
and Survivors In_l948

Dietary intake alone is not indicative of nutritional

status, as it ignores factors of absorption and utilization.

:For this reason, hemoglobin and serum vitamin A, carotene,

rand ascorbic acid levels, were examined for both groups of

ssubjects in 1948 (Table III-4). No differences were

observed. Only two women had hemoglobin levels below

142.0 gm/lOO m1; one deceased and one survivor had values of

1.1..9 and 11.0 gm/lOO ml, respectively. Alternatively, two

ESLirvivors and four deceased had serum ascorbic acid levels

k>ealow 0.4 mg/100 ml. In contrast, two survivors were

Observed to have less than 10 ug vitamin A/100 m1 serum,

Whereas the lowest value recorded among the deceased was

1255 ug.

Efligtrient Intake and Age at Death

When the nutrient intake of the deceased subjects
V9513 analyzed in respect to age at time of death, the only

1111trient in the diet found, on an absolute basis, to be

142

Table III-4.--Biochemical Parameters of Subjects in 1948.

 

 

Serum Parameter Deceaseda Survivorsb
Hemoglobin (9/100 ml) 13.5 i 1.1 13.1 i 0.8
Vitamin A (ug/100 m1 43.1 r 11.0 37.1 i 18.2
Carotene (ug/lOO ml) 99.0 i 47.1 83.9 r 32.8
Ascorbic acid (mg/100 ml) 0.87 i 0.42 1.00 i 0.44

 

an=33. These women died during or prior to 1972.

bn=17. These women were interviewed in 1948 and
1972; records used in this calculation were secured in 1948.

Values expressed as mean i S.D.

None of these values were Significantly different.

Significantly related to length of life, was dietary fat.
The higher the intake of fat, the Shorter the life. As
shown in Figure III—l, as the daily intake of fat increased
by one gram, lifespan decreased by 0.12 years, or approxi—
mately 44 days. However, not only the absolute amount of
fat in the diet but also the percent of calories contri-
buted by this nutrient, may alter the lifeSpan. The
coefficient of correlation (r) was even higher when the
percent of calories contributed by fat or carbohydrate, was
related to the length of life (Figure III-2). The higher
the percent of calories obtained from fat, the fewer the
calories contributed by carbohydrate, and the shorter the
life. One possible explanation for the deleterious effect

of dietary fat could relate to high caloric density with

143

Figure III-1.--Inf1uence of the Amount of Dietary Fat Upon
Age at Death.

*The dietary intakes are based on the
dietary records secured in 1948.

AGE AT DEA TH

I00

40

144

Y=87-OHX
. n=eo r=—o.27o p=.05

 

 

LI: 1 lil l J 14
I5 3045 6075 90|05|20l35|50

FAT INTAKE (g)

 

145

Figure III-2.--Fat and Carbohydrate as Percentages of the
Dietary Caloric Intake in 1948 and Age at
Death.

*The dietary intakes are based on the
dietary records secured in 1948.

AGE AT DEATH

I00

80

70

60

50

4o

 

 

146

 

--CARBOHYDRATE CALORIE 7.
Y . 57 + 0.46X
n = 60‘ r =O.356 p<.0l

.. FAT CALORIE %
Y: lOO-O.5|X
n = 60 r=-o.354 p< .0:

 

 

 

l l l l I

 

20 30 4O 50 60
PERCENT OF CALORIES

Q)

(3

147

resultant obesity. In Figure III-3 are plotted the relative
weights of the Lansing women as a function of dietary fat.
Among these women, relative weights were not influenced by
the level of fat consumed.

Inasmuch as the women varied in age at the time of
the survey, dietary factors were examined in relation to
the expected years of life at the time of the survey as
suggested by census life tables and insurance statistics,
and the actual years lived. A negative relation between
the fat content of the diet and expected age, was suggested.
Women who died 10 to 15 years earlier than expected were
ingesting 46.6 percent of their total calories as fat,
whereas individuals living at least ten years longer than
anticipated had, in their diets, only 37.4 percent fat
(p<.07). Preliminary calculations, based upon death
certificates from 52 subjects, revealed a significant
inverse relationship between dietary fat and expected age.
However, included among the eight subjects for whom certi-
fication of death was obtained at a later time were several
whose experience differed from the previous conclusion.

One individual, who survived 12 years beyond her expected
age of 81, was consuming 93 grams of fat daily in 1948.
Similarly, the woman with the highest daily fat intake,

125 grams, in the initial survey, lived two years beyond
her expected age of 78. In contrast, one subject aged 84
in 1948, died two years before reaching her expected age of

89, yet included only 36 grams of fat in her daily diet.

148

Figure III-3.--Influence of Relative Weight* Upon Age at
Death.

*Society of Actuaries, 1959. Build and
Blood Pressure Study, Chicago, Illinois.

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AGE AT DEATH

50

40

 

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150

Blood Pressure and Age at Death

Systolic and diastolic blood pressure are usually
considered to be important determinants of length of life.
Among these subjects neither systolic nor diastolic blood

pressure aS measured in 1948, was related to age at death

or expected age.

Nutrient Intake and Cause of Death

The immediate causes of death of the 60 deceased
subjects are Shown in Table III-5. Cardiovascular-renal
disease was responsible for 45 percent of all fatalities
and cerebrovascular disorders caused the deaths of an
additional 18 percent. About one-fifth of the women were
stricken with some form of malignancy, and six died of
pneumonia. "Senility" and diabetes mellitus were given as
the immediate causes of death for one and two subjects,
respectively.

For further examination, the category of
cardiovascular-renal disease was divided into sub-headings:
(1) symptomatic heart disease which included primarily
those individuals dying of congestive heart failure,
representing an illness of some duration, and (2) acute
arteriosclerotic or ischemic heart disease, including
;patients suffering an infarct, occlusion or thrombus, with
sudden death.

Congestive heart failure (symptomatic heart disease)

snas the leading cause of death among these women,

 

Table

I

151

Table III—5.--Immediate Causes of Death of Subjects Who
Died in or Prior to 1972.

 

Cause Incidence

 

Cardiovascular-renal disease 45% (27)

Symptomatic heart disease (400-404, 427-429)* 30% (18)

Arteriosclerotic disease (410-414, 441-444) 15% (9)
Cerebrovascular disease (430—438) 18% (11)
Cancer (140-209) 22% (13)
Respiratory disease (480-486, 514) 10% (6)
Diabetes mellitus (250) 3% (2)
Senility (794) 2% (l)

 

*International Classification of Diseases, Adapted
for Use in the United States, Eighth Revision, 1967.

n=60

responsible for 18 fatalities. As to the influence of
dietary pattern, the subjects with this syndrome tended to
have lower intakes of thiamin than those who did not, values
equalled 0.79 and 0.89 mg per day, respectively; however,
this difference was not Significant. Alternatively, a
combination of nutrients was implicated with this disorder.
As noted in Table III-6, multiple regression analysis
revealed that thiamin and four other nutritional para—
meters: fat, fat calorie percent, protein calorie percent,
and carbohydrate calorie percent, could predict the
incidence of death from symptomatic heart disease. Degree

of body fat was not a predisposing factor in that individuals

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. Pd

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152

Table III-6.--Prediction Equation Relating Nutrient Intake
in 1948 and Death From Symptomatic Heart
Disease Among Subjects Dying in or Prior to

 

 

 

 

 

 

 

1972.
y = -31 + 0.31bl - 0.0095b2 + 0.0076b3 + 0.39b4 + 0.32b5
Regression Beta Partial Signi-
Nutrient Coefficient Weight F ficance
bl Fat calorie % +0.31 +4.21 6.116 .017
b2 Thiamin -0.0095 -0.48 9.692 .003
b3 Fat +0.0076 +0.36 4.157 .047
b4 Protein calorie % +0.39 +2.85 8.441 .005
b5 CHO calorie % +0.32 +4.84 6.499 .014
Analysis of Variance for Regression
Sum of Degrees of Mean Signi-
Squares Freedom Square F ficance
Regression 2.8 5 0.565 3.133 .015
Error 9.0 50 0.180
Total 11.8 55

 

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with congestive heart failure had, on the average, a
relative weight (Society of Actuaries, 1959) of 102.3
whereas those not affected were within 99.8 percent of

their "standard" weight. That long-term arteriosclerotic
heart disease may lead to congestive heart failure is
suggested by the correlation (r=0.335, n=60, p<.05) existing
between reported death from symptomatic heart disease and

a previous history of coronary arteriosclerosis.

AS to the influence of blood pressure upon subsequent
congestive heart failure, diagnosed hypertension was
Significantly related (r=0.400, n=60, p<.01) to the
incidence of death from this disease. As shown below, in
1948, 90 percent of those who later suffered congestive
heart failure had systolic blood pressures above 150 mm.
This was true for only 62 percent of the subjects who died
of other causes. Similarly, diastolic hypertension (above
90 mm) was observed to be twice as frequent among the

individuals who eventually died of symptomatic heart

 

 

disease.
Cause of Death
Symptomatic Heart Disease Other
Systolic Hypertension 90% 62%
lDiastolic Hypertension 50% 24%

£Advancing age may increase the probability of death from
(congestive heart failure, as subjects exhibiting this
Esyndrome were older at the time of death (80.8 years versus

'77.6 years for those dying of other causes).

 

 

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In contrast to the findings with symptomatic heart
disease, acute cardiac attack (infarct or occlusion) was
unrelated to either nutrient intake, age at time of death,
relative body weight, or blood pressure. The nine indi—
viduals suffering a sudden attack actually had lower
intakes of total protein, animal protein, and fat. The mean
age at death was 80.4 years, approximately equal to that
found among women dying of congestive heart failure.
Incidence of acute cardiac attack was positively associated
with hemoglobin levels although this difference was not
significant.

Cerebrovascular attack including cerebral aneurysm
or thrombus was the immediate cause of death for 11 sub-
jects. Dietary fat appeared to be related to the develop-
ment of such disorders. The individuals who died as a
result of cerebrovascular attack had significantly higher
intakes of fat (86.7 grams/day versus 70.3 grams, p=.05),
compared with those dying of other causes. As might be
anticipated, the women with the higher intakes of fat also
consumed more calories, 1779 versus 1545, but this differ-
ence was not Significant (p=.07). Age was not a factor in
regard to cerebral attack and neither was relative weight;
the subjects suffering this complication were slightly but
Inot Significantly underweight (relative weights equalled
93.7 and 102.2). Contrary to expectations, systolic and
diastolic hypertension were, in 1948, less frequent among

'the subjects who later evidenced cerebrovascular disease.

155

Generalized arteriosclerosis was, however, positively
correlated with incidence of this disorder.

In contrast to the findings regarding cerebral
complications, cancer deaths were not Significantly related
to nutrient intake. Those individuals with a malignancy
had higher dietary levels in 1948 of thiamin and niacin,
but less ascorbic acid. The outstanding characteristic of
those whose death was attributed to cancer, was their
younger age; it averaged 73.0 years compared with 80.2
years for those dying from other causes (p<.01).

Respiratory disease is a frequent complication of
immobilization or complete bed rest in elderly patients.
The nutritional status of these subjects did not appear to
influence their susceptibility to respiratory disorders.
The Six subjects whose deaths resulted from such compli-
cations did have lower intakes of both total protein and
animal protein, and were of lower relative weights; fre-
quently, however, respiratory disease was the immediate
consequence of physical trauma (i.e., broken bone or
surgery).

Nutrient Intake and Chronic Disease
Contributingto Death

The incidence of chronic conditions in these women
which, according to the attending physician contributed to
the immediate cause of death, is listed in Table III-7.
Generalized arteriosclerosis was a complicating factor

among 53 percent of the subjects. The development of this

Y
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156

Table III-7.--Incidence of Physical Disturbances Contributing
to Cause of Death Among Subjects Who Died in or
Prior to 1972.

 

 

 

Physical Condition Incidence
Generalized arteriosclerosis 53% (32)
Arteriosclerotic heart disease 45% (27)
Hypertension 20% (12)
Diabetes mellitus 10% (6)
Nephritis-nephrosclerosis 8% (5)
Bone fracture 7% (4)
Surgery (complications--cancer, diabetes) 7% (4)
Malnutrition 2% (l)

n=60

For a majority of subjects more than one disturbance
was indicated, therefore the total percentage exceeds 100.
condition was not related to nutrient intake, nor to
relative weight. Furthermore, the women with generalized
arteriosclerosis lived longer, with average age at death
being 81.4 years as compared with 75.1 years for the other
subjects.

The incidence of arteriosclerotic heart disease was
related to the intake of a variety of nutrients. This
disease, as shown in Table III-8, was negatively related
to intakes of thiamin and calcium, and positively associated
with levels of animal protein and the relative degree of
calories contributed by the macronutrients. The magnitude

of the beta weights (standardized partial correlation

Table

 

157

Table III-8.--Prediction Equation Relating Nutrient Intake
in 1948 and Diagnosed Arteriosclerotic Heart
Disease in Subjects Dying in or Prior to 1972.

 

 

 

 

 

 

 

y = -31 -0.0063bl + 0.021b2 + 0.32b3 + 0.32b4 -0.00089b5 +
0.35b6
Regression Beta Partial Signi-
Nutrient Coefficient Weight F ficance
b1 Thiamin -0.0063 -0.29 4.841 .033
b2 Animal protein +0.021 +0.60 7.348 .009
b3 Fat calorie % +0.32 +4.01 5.698 .021
b4 CHO calorie % +0.32 +4.48 5.805 .020
bS Calcium -0.00089 -0.45 7.660 .008
b6 Protein calorie % +0.35 +2.33 6.522 .014
Analysis of Variance for Regression
Sum of Degrees of Mean Signi-
Squares Freedom Square F ficance
Regression 4.3 6 0.725 3.708 .004
Error 9.6 49 0.195

Total 13.3 55

 

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coefficients), listed for each parameter in the equation,
suggest that the percent of calories in the diet coming
from carbohydrate and fat are the strongest determinants in
the relationship.

Upon closer examination, both the level and nature
of the protein in the diet appear to be involved with the
develOpment of arteriosclerotic heart disease. Those who
developed this condition secured 14.2 percent of their
calories from protein, whereas the others secured only
12.1 percent (p=.05). Although the total protein in the
diet did not differ, animal protein was consumed at a level
of 34.0 grams per day by the women with arteriosclerotic
disease versus 27.5 grams for the other subjects (p=.08).
The women who exhibited arteriosclerotic heart disease
tended to be older at the time of death than were the women
relatively free of this disorder (81.1 years versus 76.4,
p=.052).

Hypertension was a complicating factor in the
deaths of 20 percent of the women. This condition was not
related to nutrient intake, age at death, or relative body
weight. In contrast, women with diastolic pressures above
90 mm when measured in 1948, died Slightly earlier than
expected (p=.07) when compared with the normotensive sub-
jects. Hemoglobin levels, however, were positively corre-
lated (r=0.377, n=32, p<.05) with diagnosed hypertension.

Although nutrient intake was not related to hyper-

tension per se, there was an association between the actual

9‘ IL . 1 Vi 1\ Q .
«U «O “we \Hu AH

159

systolic pressure measured in 1948 and dietary fat. That

relationship can be expressed as:

y = 119 + 2.1 bl - 0.47 b2

where 9 is the systolic pressure in mm mercury, b1 the per—
cent of dietary calories from fat, and b2 the grams of fat
in the diet (Analysis of variance for regression, Appendix
(B-3). Fat contributed a Significantly higher percentage
of the total calories to the diets of women with high
diastolic pressures also, as compared to individuals with
pressures below 90 mm (44.3% and 39.7% respectively, p<.05).
AS the calories from lipids increased, those from carbohy-
drates decreased in the diastolic hypertensive subjects,
although this difference was not Significant (p=.06).

Diabetes mellitus is frequently a metabolic compli-
cation of advancing years. The six diabetics were signifi-
cantly overweight (relative weight 118.7 versus 98.2 for
the other subjects). It was not possible to evaluate blood
pressure with diabetes, inasmuch as blood pressure values
were available for only two diabetics. One of these had
systolic hypertension, whereas neither individual had an
abnormally high diastolic pressure.

Kidney involvement, either acute nephritis or
nephrosclerosis, contributed to the deaths of five subjects.
.Although these women were similar in age to those without
kidney disease, they consumed fewer calories, less protein,

calcium and thiamin. Although the dietary level of

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vegetable protein was equal in both groups, animal protein
intakes were lower among those with kidney involvement.
Body weight was a significant factor in the etiology of the
nephrotic syndrome (relative weight among the women with
kidney disease was 118.6 versus 98.6 among the others).
Eight subjects underwent surgery in the month
preceeding death. Four suffered falls with subsequent
broken bones; for three, surgery was necessitated by
malignant growth; and for one, amputation of the leg
resulted from diabetic gangrene. The mean age at death of
the eight individuals requiring surgery did not differ from
the group at large. Although age was not a factor, these
eight women were, in 1948, consuming significantly less
energy, fat, carbohydrate and iron. DeSpite the lower
caloric intakes of the subjects undergoing surgery, protein
as percent of total calories was higher, equalling 15.4 in
these subjects and only 12.7 among the others. The women
undergoing surgery had markedly lower relative weights

(88.5 versus 102.2, p=.05).

Nutrient Intake and Physical Symptoms

 

At the time of the survey, subjects were questioned
about various physical symptoms which might be indicative
of organic disease. As shown in Table III—9, 67 percent
reported unexplained tiredness, and an equal number, joint
pains. Persistent backache, headache, shortness of breath,

and fluid retention in the lower extremities, were the next

Table

 

vv ‘ " 1
Uriefsp‘

Pains

SOres

\.
“05801

161

Table III-9.—-Incidence of Physical Complaints in 1948
Among Subjects Who Died in or Prior to 1972.

 

 

 

Complaint Incidence
Unexplained tiredness 67% (40)
Pains in the joints 67% (40)
Persistent backache 47% (28)
Shortness of breath 43% (26)
Persistent headache 42% (25)
Swelling of ankles 38% (23)
Loss of appetite 32% (19)
Stomach pain 27% (16)
Chest pains 27% (16)
Skin rash 20% (12)
Sore mouth or gums 18% (ll)
Sores that do not heal 17% (10)
Nosebleeds 8% (5)

n=60

A majority of subjects listed a number of complaints,
therefore the total percentage exceeds 100.

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162

most frequent discomforts. As to the frequency of physical
complaints among individuals, two of the Sixty women were
free of all symptoms. Seven individuals had only one
complaint and twelve subjects reported two or three com-
plaints. Twenty-one or approximately one-third of the
women were annoyed by four or five of the physical symptoms
tabulated, and 11 women reported six to seven symptoms.
Seven subjects had eight or more physical complaints, with
11 complaints being the highest number reported. Of the
seven individuals with one symptom, two had joint pain.
The other five mentioned tiredness, skin rash, sores that
did not heal, swollen ankles and dypsnea. Headache, joint
pain, stomach pain, tiredness and loss of appetite, were
each noted by two of the Six women reporting two symptoms.
When nutrient intake was examined in respect to the
incidence of physical symptoms, it was found that chronic
tiredness was not in these women the result of reduced
levels of dietary iron. This value did not differ between
those who were and were not chronically tired--on1y one
individual who complained of tiredness had a hemoglobin
value below 12 gm/100 ml. The women in both groups had
the same intake of animal protein, suggesting that vitamin
.B12 intake was not a factor; however, no measure of vitamin
Iabsorption was available. Neither age nor body weight
Significantly influenced reports of tiredness. Those who
Icomplained of fatigue had higher diastolic blood pressures

'than those who did not. Nearly one-half of the women who

 

were C

 

90 mm,

163

were chronically tired had diastolic pressures exceeding
90 mm, whereas no one in the other group had elevated
blood pressure.

In contrast to the symptom of unexplained tiredness,
joint pains were associated with higher relative weight.
For those with pain, this value was 105.7 as compared with
a relative weight of 91.8 among those not experiencing this
discomfort. Women with joint pain tended to have higher
dietary intakes of ascorbic acid, although serum ascorbic
acid levels were similar in both groups. Persistent
backache, however, was not related to either body weight or
age in 1948.

Shortness of breath appears to be a function of age.
Those subjects with limited adaptation to exercise were
aged 69.3 years in 1948 versus 64.6 years for those without
this difficulty. Neither relative weight nor blood pressure
was associated with dsypnea. In contrast, low thiamin
intake may be related to cardiac involvement and subsequent
fluid retention. Those women whose ankles swelled consumed
only 0.76 mg of the vitamin each day versus 0.94 mg reported
by those not so affected. Systolic blood pressure also
tended to be lower in those persons with fluid retention.
The lowest systolic pressure observed among the women with
:no fluid retention was 140 mm; alternatively, two indi-
viduals with swollen ankles had pressures below this level.
JLow diastolic blood pressures, on the other hand, were

associated with complaints of persistent headache.

rEpC

\

(I)
(J
H

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164

Contrary to what might be anticipated, ascorbic acid
intake was not Significantly related to the incidence of
sore mouth and gums, or sores that would not heal; however,
dietary intake did tend to be lower among those with these
abnormalities. As to the influence of other nutrients,
women who reported these symptoms had lowered iron, niacin
and thiamin, in their daily diets. Reported loss of
appetite by subjects would appear to result from higher
intakes of fat. Those experiencing prolonged satiety were
ingesting 81.3 grams of fat daily, whereas the others
consumed only 69.0 grams.

Although none of these physical symptoms were corre-
lated with age at death, several were associated with
reported causes of death. Women who died as a result of
cardiac failure had complained previously of dyspnea
(r=0.345, n=60, p<.05). Those subjects with arterio-
sclerotic heart disease had persistent backache (r=0.288,
n=60, p<.05) and stomach pain (r=0.384, n=60, p<.01). Sore
mouth, swollen ankles, and joint pains, were frequently
observed among the diabetic women.

Upon examination in 1948, subjects were rated
according to an index of aging as seen in Table III-10.
'rhe rating chart was not complete for all subjects, conse-
quently 55 women were included in the calculations for
graying of hair and wrinkling of skin and 56 for hearing
lossIand movement. Graying, skin changes, and impaired

ihxzomotion, all appear to be functions of age. Hearing

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mmoq
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166

loss, however, would seem to be non-specific, with only
three subjects experiencing marked hearing loss. Relative
weight was not a factor in respect to difficulties in

locomotion.

Discussion

 

Nutrient Intake and Longevity

 

Vitamins.--The results of the present study lend

 

support to the suggestion of other investigators (Chope,
1954; Kelley et al., 1957) that nutrient intake may influ—
ence the length of life. Chope (1954) noted higher mortal-
ity among those subjects who had low intakes of vitamin A,
niacin, and ascorbic acid. A similar Situation was observed
among the Lansing women, in that the mean dietary intakes
of all three vitamins tended to be lower for those now
deceased, although ascorbic acid only, was Significantly
lower. A further report on the 577 Californians initially
studied by Chope and Breslow (1956) indicated that both
serum vitamin A and ascorbic acid levels were positively
related to longevity. Such an association was not
evident in the Lansing study; however, serum parameters
were available for only 33 of the 60 deceased subjects.
Similarly, Kelley and coworkers (1957) observed that
mortality was higher for those individuals who consumed less
than.40 percent of the RDA for one or more nutrients. This

Deletion was true for vitamin A, niacin, and ascorbic acid,

in t‘r
were

SHIV.

167

in the 1972 evaluation, although subjects now deceased

were less likely to be low in calcium intake than were

survivors.

Ca1cium.--There is considerable controversy about
the possible merits of high intakes of calcium. Some of
the early work with animals, investigating the effects of
high levels of dietary calcium, was done by Campbell and
associates (1943). They observed in Osborne-Mendel rats
that lifespan was increased when the calcium level in the
ration was raised from 0.20 to 0.35 percent. However,
levels of calcium above 0.35 percent had no effect, in that
the rate of growth or lifeSpan of rats fed rations con-
taining either 1.0 percent calcium throughout life, 1.0 per—
cent during growth and 0.70 percent thereafter, did not
cent during growth and 0.22 percent thereafter, did not
differ. Those authors (Campbell et al., 1943) concluded
that when the optimum requirement was met, further supple-
mentation had no beneficial effect. In this regard, Garn
(1970) proposed that the adult requirement for calcium is
approximately 200 mg daily. This is in contrast to the
recommendation of 800 mg, put forth by the National
Research Council (Food and Nutrition Board, 1953). Using
this criteria, 17 of the deceased subjects and 10 of the
survivors were, in 1948, consuming less than 40 percent of
the recommended level of 320 mg. If Garn's suggested level

of calcium intake is accepted (200 mg), then only four of

the

8080

Pro

168

the deceased subjects and one of the survivors, had in-

adequate intakes of this mineral.

Protein.--There was a suggestion in the Lansing study
that dietary level of animal protein may have a positive
effect on longevity. According to the 1948 diet records,
the women who have survived had higher intakes of animal
protein than those who did not. Among the deceased,
however, there was no relationship between dietary protein
and age at death (r=0.022). Although survivors tended to
have higher intakes of animal protein, low intakes of this
nutrient do not necessarily reduce the lifespan. This idea
comes from the fact that one woman, aged 78 in 1948, whose
daily intake of protein was 32 grams or 53 percent of the
RDA (Food and Nutrition Board, 1953), consumed only nine
grams of animal protein each day. Despite this intake, She
survived to the age of 88, or two years beyond her expected
age.

Furthermore, epidemiological evidence does not
support the conclusion that increasing levels of dietary
protein are beneficial to health and well—being. Watanabe
and coworkers (1968), comparing nutrient intake in a total
of 29 advanced and underdeveloped countries, reported that
the quantity of meat consumed provided the strongest
association with degenerative heart disease.

Similarly, protein intake has been Shown to influ-

ence kidney regulation. This may have important consequences

inasm'
cent
(Shoe

incre

169

inasmuch as normal aging is accompanied by a 50 to 60 per-
cent reduction in the number of functional nephrons

(Shock, 1970). The latter effect is associated with an
increase in blood urea nitrogen (BUN). When the intake of
acid-producing animal protein is restricted, with the
substitution of alkali-producing vegetable protein, BUN
levels fall within normal ranges (Lyon et al., 1931). Such
a change may enhance normal kidney function throughout a
longer fraction of the lifespan.

Studies with animals have not provided any clear-cut
evidence regarding the effect of dietary protein upon
health and/or longevity. Ross (1961) observed no reduction
in the average lifeSpan of rats fed the minimal level of
protein required for good growth. In contrast, the length
of life was increased when calories were restricted con-
comitantly. In these animals, however, excessive levels
of dietary protein were associated with increased nephrotic
degeneration. Similarly, Nakagawa and Masana (1971)
reported no differences in the lifespan of rats fed rations
containing 10, 18, or 27 percent casein.

One factor which must be considered in regard to the
Iiigher intakes of protein in 1948 by those who have survived,
is age. These subjects were younger at the time of the
.initial survey, whereas the deceased subjects were of
retirement age. Differences in the consumption of animal
protein may reflect the amount of money available for food

expenditures by these two groups. The individuals on a

reti:

SGIV

C17

ff)

(7

 

170

retirement income may have been forced to limit their
servings of meat as a result of cost.

A second factor influencing this difference in
animal protein intake between women of two different ages,
may be the change in the consumption pattern of most people
in the United States which has occurred during this century.
In 1900, only one-half of the protein intake was obtained
from animal sources, whereas today, two-thirds comes from
animal foods (Sw0pe, 1970). The dietary survey conducted
in 1972 revealed that survivors have continued to consume
generous amounts of animal protein and are still, for their
age, in relatively good health. Of greater importance may
be the fact that these women have, in the past 24 years,
Significantly reduced their intakes of calories and fat;
this may be a vital determinant in the prolongation of their

lives.

FEE.—-The finding that age at death was inversely
related to dietary fat may be of practical Significance.
Burrill and associates (1959), studying 349 women from the
North Central states who ranged in age from 30 to 97 years,
found that dietary fat equalled 72 grams daily, or 38 per-
cent of total calories. Fat intake among the Lansing women
in 1948 was about 73 grams, but, as a percent of total
calories, equalled in survivors and decreased 38.6 and 41.3,

respectively. This difference was not significant; however,

fat cal

at deat

health
associ
intake

TIQIta.

171

fat calorie percent was negatively correlated with both age
at death and expected age.

The relation of various levels of dietary fat to
health and longevity has been evaluated by Watanabe and
associates (1968). These investigators compared the fat
intake of the populations of various countries with
mortality statistics and incidence of degenerative disease.
Regression analysis revealed an inflection on the curve,
with a Shift from a positive to a negative influence, at an
intake of 50 to 60 grams fat, a range 10 to 20 grams less
than that consumed by both survivors and deceased in 1948.
According to the dietary information collected from the
survivors in 1972, fat intake had, over the intervening
years, dropped to 51 grams daily. This value compares
favorably with the calculations of Watanabe et a1. (1968).

The suggestion of a deleterious effect of dietary fat
upon the lifespan has been confirmed by several investi—
gators (French et al., 1953; Silberberg and Silberberg,
1954; Schemmel et al., 1973) working with various animal
models. The Silberbergs (1954) concluded that a diet high
in fat (29% lard), when fed to mice, resulted in higher
mortality, regardless of strain, sex, age, or weight gain.
The deleterious effect of this regimen was more conspicuous
.in animals of a long-lived as compared with a Short-lived
strain, in males than in females, and when fed from the age

of one year rather than from weaning. In that study, the

rate I

incre

o'u
MO
(.0
CU)

172

rate of mortality was positively associated with the
increase in body weight.

Similarly, French and coworkers (1953) noted a
significant decrease in length of life among rats of both
sexes fed a diet in which corn oil provided 22.7 percent
of total calories. Histological examination revealed a
high fat content in the liver of males fed the corn oil
ration, as compared with controls given a low-fat, high-
carbohydrate mixture. The cause of premature death in
these animals, however, could not be ascertained. As was
also noted by the Silberbergs (1954), the deleterious effect
of the high fat ration was less pronounced in females.
Schemmel and associates (1973) observed that rats suckled
by dams fed either a high fat (60%) or grain (3% fat) ration,
and then weaned to one of these rations, experienced the
highest mortality when nursed by high-fat fed dams and

weaned to that ration.

Possible Mechanism of Action
of Dietary Fats

The mechanism whereby dietary fat shortens life is
not known. A number of possible explanations exist. One
of these involves the obesity that may result from the
consumption of a high fat diet. This type of obesity has
.been observed in animals (Mickelsen et al., 1955). Excessive
lmody fat may accelerate the develOpment of a variety of
chronic disturbances leading to an early death. In the

present study, obesity would not appear to be the means by

whiI

EXpI

IIIOI'

fir

in

Was
sce
rel

car

173

which dietary fat shortened the life, as relative body
weight was not associated with either age at death or
expected age.

Another possible mechanism by which fat may hasten
mortality is an effect upon the cardiovascular system. At
first glance, this hypothesis would seem to be supported
by the present results. For these women, fat intake, both
in absolute terms and as a percentage of caloric intake,
was related to both symptomatic heart disease and arterio-
scelerotic complications. The actual Significance of this
relationship is questionable, Since the true incidence of
cardiovascular deaths among the elderly is difficult to
determine. Any "sudden death" among these individuals is
frequently described as a cardiovascular accident. AS
emphasized by Mueller-Deham (1946), in senescence, a number
of diseases are likely to occur in the same individual,
thus making it exceedingly difficult to attribute death to
a Single cause.

The relationship of fat intake to blood pressure
deserves further scrutiny in that Stamler (1962) suggests
that arteriosclerosis and hypertension are two distinct
diseases, despite the fact that one usually accompanies the
other. A prior study of women in the North Central states
(Burrill et al., 1959) revealed no relationship between fat
intake and blood pressure. In contrast thereto, the
results of the present study of the deceased Lansing women

suggeSt that dietary fat, both on an absolute basis and as

a:

(31'

at
CC
Pr
ar

SL1

174

a percentage of total calories, contributed to the prediction
of systolic blood pressures.

Results supporting those observed in the Lansing
study have been reported from Czechoslovakia. There, Hejda
and coworkers (1967) noted among 12,000 aged persons examined
that those with low blood pressure (precise value not
stated), consumed 84.4 grams of fat each day. This mean
value increased to 112.6 grams daily for those individuals
with high blood pressure; however, the difference between
the two levels was not Significant.

Further attempts to determine the mechanism whereby
dietary fat shortens life have been directed toward the
presence of toxic substances in the fat itself. Consider—
able work has been carried on by Kaunitz et a1. (1966) who
concluded that fresh olive, soybean and corn oils, despite
processing for human consumption, contain compounds which
are toxic to rats. Further work (Kaunitz et al., 1970)
suggested that whether the fat was oxidized or not, its
inclusion in the ration at a level of 20 percent, decreased
longevity in rats. This effect could not be attributed to
linoleate content, melting point or degree of unsaturation.
It was concluded that non-triglyceride components may be
involved in this "toxicity." Another aspect of this
problem was demonstrated in humans by Dayton et a1.

(1968) who reported that older men fed diets containing

jLarge amounts of unsaturated fats responded with some change

in
in
lo
fa
is
re
ti
'80
in

Ca:

die

The

fit

tan

and

the

the

175

in serum cholesterol levels; however, cancer mortality was
increased.

Another factor in the relation of dietary fat and
longevity involves a possible change in the distribution of
fat within the body as individuals age. The basis for this
is the suggestion by Skerjl and coworkers (1953) that the
percentage of body fat increases with age, while body weight
remains stationary. This may be the result of fat infiltra-
tion of organs and muscles, with compensatory loss of lean
body mass. Whether this change is enhanced or accelerated
by increased levels of dietary fat remains a matter of
Speculation. The accompanying loss of vital tissue from
the fat-infiltrated organs, might shorten the lifespan.

An alternative proposal to that which assumes a
deleterious effect of dietary fat, is the consideration of
the high fat diet as deficient in cellulose or crude fiber.
In most cases, the incorporation of large amounts of fat
in the diet is at the expense of plant products adding
carbohydrate and fiber. The importance of fiber in the
diet has been stressed by Painter and Burkitt (1971).

These workers, on the baSiS of epidemiologic evidence,
suggest a Significant negative relation between dietary
fiber and the incidence of diverticulosis and colonic
cancer. Prior to the recent emphasis upon colonic cancer
and related disturbances of the lower intestinal tract, the
therapeutic role of cellulose and pectins was limited to

the control of serum cholesterol levels. Presumably,

176

pectins reduce the reabsorption of bile acids (Leveille
and Sauberlich, 1966). Other possible roles of fiber, in
addition to the maintenance of normal intestinal function,

remain to be elucidated.

Mortality and Cause of Death

 

The causes of death among the 60 Lansing women are
statistically similar to those of the United States white
female pOpulation. Since only two of the 60 subjects in
the present study died before reaching 65 years of age, that
was the lower range used in comparing United States vital
statistics with the present results. In the United States
women above 65 years of age, diseases of the heart are
responsible for 46 percent of all deaths (MetrOpolitan Life
Insurance Company, l971e); this was also true for the
Lansing women. Cerebrovascular disease was reported to be
the cause of death for 18.0 percent of the Lansing subjects,
a value which compares with the national percentage of 16.6.
Among United States women over the age of 65, malignant
neoplasms are responsible for 14 percent of all deaths,
whereas 23 percent of the Lansing women had this disease.
For younger United States women aged 45 to 65, however,
one-third of all deaths are attributed to cancer of some
form. Both Lansing subjects who died before the age of 65,
succombed as a result of this disease.

There are some differences between United States

vital statistics and the Lansing results as to the incidence

of \
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one
can
dea
or;
amo
lun
bel
won
81::
of

th:

hi;

177

of various types of cancer. Although cancer of the breast
iS the most frequent form among United States women, only
one subject in the present study presumably died from that
cancer. Malignancy of the intestinal tract caused four
deaths, and three women had cancer of the reproductive
organs. Intestinal cancer is second highest in incidence
among United States women, followed by malignancies of the
lungs and reSpiratory system. Since the Lansing women
belonged to a generation in which cigarette smoking by
women was less frequent, cancer of the lungs and reSpiratory
system might be leSS likely to occur. Leukemia, myeloma
of the bone marrow, Hodgkins disease, a brain tumor and
thyroid cancer, each caused one death.

Few specific relationships could be established
between nutrient intake and the cause(S) of death as listed
on the death certificates. Those women for whom death was
attributed primarily to symptomatic heart disease had low
dietary thiamin levels. This provides some support for the
findings of Chope (1954) that thiamin intakes below 0.8 mg
daily were associated with circulatory disease. Although
high intakes of calories and fat are generally considered
to promote the development of this syndrome, in the current
study, a multiplicity of nutrient factors were associated.
Such a Situation suggests that the relationships between
cardiovascular disease and diet which have been suggested

from studies of males may not be true in females.

was sig
to bee
advanc
result
proees
Stress

10 tn

in

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178

Among the Lansing women, generalized arteriosclerosis
-was significantly related to age at death, suggesting this
to be a non-Specific degenerative process continuing in
advanced age. Progressive arteriosclerotic lesions may
result in memory lapse or even complete loss of facultative
processes. Such unawareness to surroundings, with reduced
stress, could facilitate the adaptation of these individuals
to their environment, resulting in an extended lifespan.
Whether such an adaptation enabled these subjects to live
longer than those who were less affected by arteriosclerosis
and may have been more aware of their life Situation and
limitations, remains a possibility.

Arteriosclerotic lesions of the coronary arteries
in particular, however, would appear in these subjects to
be related to dietary intake. One nutrient which deserves
further attention in relation to the development of coronary
heart disease in women is protein. The percent of total
calories supplied by protein was significantly greater
among those exhibiting this disease. The subjects with
higher intakes of protein tended to consume more animal
protein.

In regard to disease processes, one aspect of the
present study which should not be overlooked is the
Ineasurement of "total dietary fat." This value was not
defined as to the nature of the fat. One possible
explanation for the relationship of protein calorie percent

and coronary arteriosclerosis might lie with the large

amounts I
The mean
heart d1
conditic

does not

aphasi
intake

CdIdiQt‘;
only 00
fat and

which t
thiahix
aSSQCié
CORtrij

179

amounts of saturated fatty acids found in animal foods.

The mean age at death of subjects with arteriosclerotic
heart disease was 81.1 years, suggesting that this chronic
condition, although possibly imposing physical limitations,
does not predispose women to an early death.

The results from the multiple regression analyses
emphasize the complexity when attempting to relate nutrient
intake to physiological syndromes. In reference to
cardiovascular diseases, the present data indicate that not
only do Specific nutrients interact (i.e., thiamin, calcium,
fat and animal protein), but the relative proportions in
which they are present, is also important. Although
thiamin, animal protein and fat, have previously been
associated with cardiovascular function or disease, the
contribution of calcium to an equation is an interesting
observation. The calcification of atherosclerotic plaques
seems to be a natural progression of the disease to its
more severe form. Future investigators might do well to
examine the diet as a whole, in that the level of intake
of other nutrient factors, not previously considered, may
contribute to degenerative diseases of the coronary
arteries and heart muscle itself.

In contrast to the findings regarding cardiovascular
disease, cerebrovascular attack was Significantly related
to dietary fat, and positively associated with the ingestion
of calories. Despite seemingly high intakes of calories

and fat, the subjects who developed cerebrovascular attacks

 

allevi
have E
have i

I fin
ll". 13¢

1

180

had low relative weights (93.7). Life insurance statistics
(Society of Actuaries, 1959) suggest that cerebrovascular
disorders are often related to hypertension; however, this
was not true of the Lansing women examined in 1948. This
finding may reflect the use of more effective drugs for
alleviating symptomatic hypertension, although damage may
have already occurred. Alternatively, these individuals may
have become hypertensive at some time after the examination

in 1948.

Body Weight and Blood Pressure

 

One physiological parameter associated with the
development of degenerative disease is body weight. In the
present study, relative weight as a measure of the degree
of body fatness, was significantly associated with both
diabetes and nephrotic syndrome. This finding is comparable
to life insurance data (Society of Actuaries, 1959). The
latter show that for cardiovasulcar-renal disorders and
diabetes mellitus, the mortality ratio (normal weight
individuals=lOO) of overweight women was 177 and 372,
respectively. Similarly, mortality ratios are higher for
arteriosclerotic heart disease (175) and cerebral hemorrhage
(212), among those who are excessively overweight.

The actuarial statistics suggest that in women,
elevated blood pressure predisposes the individual to
cerebrovascular or heart disease. According to Blackburn

and Parlin (1966), the pattern of mortality from

 

cardic
assoc:
body v

diastc

a COLT

181

cardiovascular-renal disease may reflect the extent of
association between elevated blood pressure and excessive
body weight. In the Lansing study, neither systolic nor
diastolic blood pressure correlated with body weight.

A study of chronic disease among the inhabitants in
a community of southern Michigan (Epstein et al., 1965)
indicated that in women over 60 years of age, heart disease
was related to systolic blood pressure but not overweight.
Alternatively, hypertensive heart disease was positively
associated with body weight. Diabetes mellitus correlated
with both systolic blood pressure and relative weight.
Comstock and coworkers (1966), studying women over 55 years
of age in Muscogee County, Georgia, found the incidence of
heart disease to rise from 98/1000 to 142/1000 with
increasing fatness, as judged by skinfold thickness. This
finding was not substantiated in the present study.
Alternatively, in the Georgia study, deaths from cere-
brovascular disease were inversely prOportional to measures
of body fat, a relationship also suggested by the relative
weights of the Lansing women.

The interpretation of the results from the present
study are subject to certain limitations. The time interval
between the collection of dietary and medical data in 1948
and the year of death, ranged from 6 months to 24 years.
What changes in nutrient intake, body weight or blood

pressure occurred during this period, are not known.

 

182

Furthermore, the information obtained from death
certificates cannot be accepted without some degree of
reservation, as autopsies are seldom performed on aged
individuals dying of natural causes. Mueller—Deham (1946)
in his review points out that an essential defect in the
reporting of deaths is the neglect of auxiliary diseases
and multiple causes. No consistent policy is followed as
to whether a severe pre-existent disease or the immediate
cause of death should take precedence on the death certifi—
cate (U.S. Department of Health, Education and Welfare,
1967). For example, diabetes may be a common cause of
death in old age, although most frequently, these patients
die from complications of the disease which could be entered
under cardiovascular syndrome or infection. Cardiovascular
disease would appear to be stressed in dubious cases.

Finally, the size of the Lansing sample is relatively
small. However, it is one of the few studies which provides
longitudinal information concerning the dietary habits and
health, and later mortality experience, of a random group

of women.

Conclusions

 

For these 60 older women, mortality would appear to
be higher in those subjects consuming less animal protein
and 40 percent or less of the recommended intake of ascorbic
acid. Low levels of dietary calcium seemingly have no

adverse effect upon lifeSpan.

 

inz
and

To:

183

Incorporation into the diet of high levels of fat
with concomitant reduction in carbohydrates, was associated
with a shortened life. There is a possibility that this
deleterious effect of dietary fat is mediated by increases
in systolic or diastolic blood pressure. Although dietary
fat was associated with the develOpment of cerebrovascular
disorders among these women, arteriosclerotic and myocardial
lesions appear to be multi-factorial in etiology involving
animal protein, thiamin, calcium, and the relative caloric
contributions to the diet of protein, fat and carbohydrate,.
as well as the degenerative processes of normal aging.

The two women who died prior to age 65 years were listed as
dying of cancer, whereas degenerative diseases of the heart
and circulatory system were the common causes of death
among the older women.

Body weight and hypertension may have aggravated
degenerative disease and so contributed to mortality, but
neither factor was directly related to life expectancy.
Physical complaints as tiredness, swollen ankles or short—
ness of breath, although causing personal discomfort, were

not associated with mortality or longevity.

this
to 2(
WW]

of Ce

CHAPTER IV

CHANGES IN FOOD INTAKE OF DECEASED AND

SURVIVORS BETWEEN 1948 AND 1972

Introduction

 

During the past decade the number of individuals in
this country, over the age of 65, has increased from 16.5
to 20 million. By the year 2000, nearly one-third of our
population will be at least 45 years of age (U.S. Bureau
of Census, 1970).

Despite the large numbers of persons in this age
category, relatively little is known about the individuals'
food habits in later life. The dietary pattern of the
older adult is a product of his lifelong experiences with
food. Although various groups of older people have been
studied in relation to their food choices, these surveys,
as concluded by Howell and Loeb (1969), do not indicate
‘whether the current food choices of the subjects are those
'which have persisted from earlier adulthood, or have been
altered by physical, social or environmental factors.
Similarly, the character and availability of foods in the

United States have changed radically during this century.

184

 

For this
above th
course o
own agin
Of those
tations

known.

national
as Patte
of a gro
in bOth
in 1948,
YGars,

aged 64

185

For this reason, food consumption patterns of individuals
above the age of 60 have, most likely, changed during the
course of their lifetime apart from any influence of their
own aging process. Whether these changes are reflective
of those observed in the general population, or are adap-
tations to the limitations imposed by advancing age, is not
known.

To further examine the influence of age and
national food trends upon specific food choices, as well
as patterns of consumption, the author examined the dietaries
of a group of women in Lansing, Michigan, who were studied
in both 1948 and 1972. At the time of the original survey
in 1948, the 103 subjects ranged in age from 40 to 88
years. The 28 survivors who were studied in 1972, were

aged 64 to 90.

Methods
In 1948-55 Ohlson and coworkers (1948, 1950, 1952,

1952a) conducted nutrition studies with 103 women in

Lansing, Michigan, who at that time ranged in age from 40

to 88 years. Each subject provided a 24-hour dietary
.recall in addition to a health and nutritional history,
61nd facts relating to marital and socioeconomic status.
Apbout one-half of the women kept written food records for
Eheariods of one to five days. Selection procedures and
'mEBthods have been described elsewhere (Chapter II, pp. 92—

93) , In 1972, the survivors of this population were

 

C\

«aw

5i

in

Q t

.WIJ

186

re-examined, and both written and recall dietary records
were secured. Twenty-eight subjects, ranging from 64 to
90 years, participated. The methods have been described
previously (Chapter II, pp. 93-95.

The nutrient intake of the deceased subjects when
measured in 1948, and that of the survivors in both 1948
and 1972, have been compared using the student's t and
paired t tests, respectively. To determine the frequency
of intake of specific food items, those foods were tabu-
lated which appeared at least once on the food records
available for each subject (Appendix C~1. C-Z). The
quantitative servings listed were those judged to be most
representative of the subject's daily diet plan. Servings
were defined according to the Exchange Lists used in
developing therapeutic diets (Goodhart and Shils, 1973).

Statistical differences were confirmed using tests of chi

square.

Results

The age distributions of the subject populations
studied in both 1948 and 1972, and age at death of the
deceased women, are shown in Figure IV-l. In 1948 the
greater numbers of subjects were between the ages of 40 and
60 with a mean of 59.5 years. The 28 c00perating survivors
in 1972 had a mean age of 74.8 years. Sixty of the sub-
jects are now deceased, having died during or prior to

1972. In Figure IV-2 are tabulated the numbers of deaths

187

Figure IV-l. Age Distribution of Subjects.

 

N
0

NUMBER OF SUBJECTS
o

01
O

188

AGE DIS 7' RIM ION 0F SUBJECTS

... ORIGINAL SUBJECTS “948)
--SURV|VORS “972)

—DECEASED SUBJECTS
#- .. ooooooooooo .. (age at death)

 

 

 

 

 

40-49 50-59 60-69 7mg 80-39 90+
AGE (years)

 

189

Figure IV-2. Number of Deaths Among Subjects in Five Year
Intervals 1948-1973.

190

NUMBER OF DEA 7H5 AMONG SUBJECTS IN
FIVE YEAR INNER/ALB /.948- A973

MV\\\\\\\\\\\\\\\\\\\\\\\\\\\\\§

l968
to
l 972

m§§

l963
to
|967

(I5)

V\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\s

I958
|962
TIME OF DEATH

0
.ol

|953
|957

0
5|

W§\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\.

I952

ww\\\\\\\\\\\\\\\\\\\\\\\\t%

. . .
5 O 5

mkbmfim§m Kb kwms<§<

 

191

occurring in each five-year interval since 1948. The
death rate would appear to have been relatively constant
over the 24-year period.

Differences in Nutrient Intake

Between 1948 and 1972

The nutrient intakes in 1948 and 1972 of the
deceased and surviving subjects are compared in Table
IV-l. The survivors were younger at the time of the first
survey, with a mean age of 52.1 years as compared with 67.4
years for those now deceased. The dietary nutrients of the
two groups in 1948 were very similar, with significant dif-
ferences noted only for protein and ascorbic acid. The
survivors consumed 58.4 grams of protein daily, in contrast
to 50.8 grams for the deceased. Similarly, the mean
ascorbic acid intakes were 73 mg and 51 mg for the sur-
vivors and deceased, respectively. Although protein intake
per se was higher among the survivors, protein as a percent
of total calories did not differ significantly between the
two groups in 1948.

Despite the fact that nutrient intakes of deceased
and surviving subjects were similar in 1948, many changes
(occurred in the diets of the survivors since that time.
jEnergy intake decreased significantly from 1683 kcalories
to 1297. Associated therewith were decreases of about 25
‘percent in carbohydrate and fat intakes. Alternatively,

protein levels remained fairly constant. Dietary vitamin A

 

192

Table IV—l.--Comparison of Nutrient Intakes of Subjects in 1948 and

 

 

1972.
1 . 2 .
Nutrient Deceased Suervors Suervors
1948 1948 1972

Calories (kc) 1580 i 394 1683 i 632a 1297 i 317a
protein (g) 50.8 i 14.2b 58.4 : 17.9b 59.2 i 15.3
Fat (g) 72.9 i 22.1 73.9 : 32.8C 51.4 i 18.8C
Carbohydrate (9) 180.5 i 53.0 196.5 i 78.2d 151.3 i 44.4d
Calcium (mg) 478 i 247 491 i 284 528 i 231
Iron (mg) 9.4 i 2.3 10.2 i 5.1 10.1 i 2.8
Vitamin A (IU) 4214 r 4408 3866 i 3728e 7969 : 8236e
Thiamin (mg) 0.86 r 0.24 0.95 i 0.53 0.91 i 0.31
Riboflavin (mg) 1.11 t 0.45 1.19 i 0.54 1.45 i 0.62
Niacin (mg) 8.4 i 3.5 9.0 : 2.3f 12.7 i 3.8f
Ascorbic acid (mg) 51 i 409 73 i 409'h 93 i 52h
protein calories % 13.1 i 3.4 14.4 i 3.41 18.5 : 4.7i
Fat calories % 41.3 i 6.4 (38.6 i 6.53 34.8 i 6.83
Carbohydrate calories % 45.5 i 7.1 47.0 i 6.3 46.8 i 7.8

 

n=60 These women died during or prior to 1972.
n=28 These women were interviewed in 1948 and 1972.

Values expressed as mean i S.D.
ZLetter pairs are significantly different, p :_.05.

Ekatal number of food records available for calculations:
Deceased in 1948 = 125
Survivors in 1948 56
Survivors in 1972 66

 

193

and niacin were higher in 1972, whereas thiamin and ribo-
flavin intakes did not differ. Inasmuch as protein
remained constant while energy values declined, protein at
the later date contributed a higher percentage of total
calories, rising from 14.4 to 18.5. Concomitantly,
calories from fat declined from 38.6 to 34.8 percent of the
total energy. Carbohydrate calories decreased in the same
proportion as did the total, with the percentage of

calories from this food source remaining the same.

Differences in Food Choices
Between 1948 and 1972

 

 

Meat, Fish, Poultry and Eggs.--The observed differ-

 

ences in nutrient intake are reflected in the foods chosen
by the women in both surveys. Sources of animal protein,
selected in 1948 and 1972, are tabulated in Table IV-2.
Beef was the most popular meat in both years. Pork was the
second most frequent choice of those now deceased, whereas
chicken was consumed more frequently by the survivors in
1948. In the initial survey, pork sausage was listed for

3 and 7 percent of the deceased and survivors, respectively.
In 1972, two individuals used liver sausage and four women
Iuad frankfurters as a main dish. Pork sausage was not
consumed by any subject in the later survey. Liver was
selected at least once by nearly one-fifth of the survivors

in 1972. Eggs were a popular protein source both in 1948

194

Table IV—2.--Meat Varieties Chosen by Subjects in 1948 and

 

 

1972.
Deceased1 Survivors2 Survivors
F°°d Item 1948 1948 1972

Beef 50% (30) 57% (16) 64% (18)
Ham 3% ( 2) 11% ( 3) 7% ( 2)
Pork 30% (18) 21% ( 6) 18% ( 5)
Veal 7% ( 4) 11% ( 3) 0 ( 0)
Chicken 7% ( 4)a 21% ( 6)a 25% ( 7)
Fish 20% (12) 25% ( 7) 36% (10)
Liver 7% ( 4) 4% ( l) 18% ( 5)
Luncheon meat 18% (ll) 28% ( 8) 25% ( 7)
Sausage/weiners 3% ( 2) 7% ( 2) 21% ( 6)
Eggs 48% (29) 50% (14) 64% (18)
l

 

2n=28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers of subjects.
Letter pairs are significantly different, X

p i .05.

n=60 These women died during or prior to 1972.

1 3.841,

Total number of food records available for calculations:
Deceased in 1948
Survivors in 1948
Survivors in 1972

125
56
66

195

and 1972. The meat varieties chosen by deceased and
survivors in both surveys were generally similar.

In contrast to this finding regarding the varieties
of meat chosen, significant differences were noted in the
number of servings of high protein foods consumed by both
groups of subjects (Table IV-3). Although all of the sur-
vivors had, in 1948, at least one serving of high quality
protein daily (meat or egg), this was not true of the
deceased women. For 20 percent of the latter, protein
intake (with the possible exception of milk) was of plant
origin. The majority of the deceased subjects (55%) had
either one serving of meat daily or a serving of meat or
egg. The comparable value for the survivors was 39 per-
cent; however, the remainder of the survivors, or 61 per-
cent, had two or more servings of animal protein each day.
The number of survivors including both meat and egg in
their daily dietary increased from 39 percent in 1948 to
64 percent in 1972. Two individuals had three servings

of meat each day in 1948, although none did so in 1972.

Vegetables, Fruits and Legumes.-—A number of changes
occurred in the consumption patterns of fruits and vege-
‘tables among the survivors. As shown in Table IV-4, the
use of dark green and deep yellow vegetables did not differ
significantly between deceased and survivors in the 1948
ciietary survey. By 1972, survivors had increased their

intake of those vegetables and fruits high in vitamin A.

 

Table IV-3.—-Amounts of Meat and

196

Eggs Consumed by Subjects in 1948

 

 

and 1972.
Food Pattern Deceasedl Survivors2 Survivors
1948 1948 1972

Meat and/or egg daily 80% (48)a 100% (28)a 100% (28)
One serving meat/day 32% (19) 32% ( 9) 18% ( 5)
Two servings meat/day 10% ( 6) 18% ( 5) 18% ( 5)
Three servings meat/day 2% ( l) 4% ( l) O ( 0)
1-2 servings meat + egg daily 13% ( 8)b 39% (ll)b 64% (18)
Either meat or egg daily 23% (14) 7% ( 2) O ( O)
No meat or egg 20% (12)c O ( O)C O ( O)

 

*Includes fish and poultry.

ln=60 These women died during or prior to 1972.

n=28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers 05 subjects.
Letter pairs are significantly different, x

Total number of food records available for calculations:

Deceased in 1948 = 125
Survivors in 1948 = 56
Survivors in 1972 = 66

3_3.84l, p‘: .05.

 

Table IV-4.--Vegetables and Fruits Chosen by Subjects in 1948 and

197

 

 

1972.
1 . 2 .
Food Item Deceased Surv1vors SurV1vors
1948 1948 1972
Deep yellow vegetable 25% (15) 14% ( 4)a 39% (ll)a
Dark green vegetable 5% ( 3) 7% ( 2) 18% ( 5)
Potato 80% (48) 78% (22) 75% (21)
Legumes 32% (19) 39% (ll) 21% ( 6)
No vegetable 0 ( O) O ( O) O ( O)
. . b b
Citrus fruit 42% (25) 78% (22) 68% (19)
Deep yellow fruit 23% (14) 36% (10) 39% (11)
No fruit 22% (13) 7% ( 2) 11% ( 3)
Vitamin A source 23% (14) 36% (10)C 64% (18)C
. . d d
Vitamin C source 43% (26) 82% (23) 71% (20)
Sources - Vitamins A and C 17% (10) 28% ( 8) 54% (15)

 

1n=60 These women died during or prior to 1972.

2n=28 These women were interviewed in 1948 and 1972.

Q

Numbers in parentheses are actual numbers of subjects.

Letter pairs are significantly different, x

Total number of food records available for calculations:

Deceased in 1948
Survivors in 1948
Survivors in 1972

= 125
56
66

_>_ 3.841, p i .05.

198

In 1948, the consumption of citrus foods was significantly
less among the deceased subjects. Although nearly twice

as many survivors (54%) had, in 1972, a good source of both
vitamins A and C, as compared with 1948 (28%), this differ-
ence was not significant (p < 0.1). Of the deceased
subjects, only 17 percent consumed good sources of both
vitamins A and C on at least one day.

Use of potatoes in the diet did not differ between
groups in 1948, nor was there a change during the inter-
vening years in the percentage of women consuming this
food. Legumes appear less frequently in current diet
records as compared with the previous study. No individual,
in either survey, omitted completely, vegetables from their
meals. In 1948, however, 22 percent of the deceased sub-
jects consumed no fruit; this was also true for 7 percent
of the survivors.

Further examination of individual diets revealed
that 25 percent of the women increased their daily servings
(of fruit between 1948 and 1972, whereas 28 percent reduced
:it. Among the latter, citrus fruit was most frequently
deleted from the meal pattern as six of the 22 subjects
vflu) included citrus in their diet in 1948, did not select
sutfll fruit in 1972. Conversely, three subjects who did

not choose citrus in 1948, had added this vitamin source

to their'diets by 1972.

 

199

The selection of vegetables in the daily meal pat-
tern was unchanged for 46 percent of the women interviewed
in both surveys. In contrast, 12 subjects added a dark
green or yellow vegetable to their daily diet over the 24-
year interval, whereas three persons deleted this food.
During the interval three women excluded potatoes from

their diets, and two individuals added this vegetable.

Dairnyoods.--The types of dairy products chosen

 

in 1948 and 1972 (Table IV-S) may explain in part, the
decline in fat intake by the survivors over the past 24
years. In 1948 only 7 and 4 percent of the deceased and
survivors, respectively, used skim milk, whereas 54 percent
of those interviewed in 1972 used a non-fat or low-fat
milk. Among the 15 individuals using a milk low in fat in
1972, 12 chose skimmed milk and three, milk with a fat
content of 2 percent. A trend toward food choices lower
in fat content is further indicated by the increased use
«of cottage cheese, and the change from ice cream, the
dessert of choice in 1948, to ice milk in 1972.
Consumption of those dairy foods which might con-
tribute:calcium and riboflavin to the diet increased mar-
ginally'between 1948 and 1972 (Table IV-6). Although only
14 percent of the survivors consumed no fluid milk in
1972, as contrasted with 28 percent of this group in 1948,

relatively few (25%) use at least one cup each day. In

200

Table IV-5.--Dairy Foods Chosen by Subjects in 1948 and 1972.

 

 

l . 2 .
Food Item Deceased Suervors Suervors
1948 1948 1972

Whole milk 75% (45) 68% (19)a 32% ( 9)a
Skim milk/low—fat milk 7% ( 4) 4% ( 1)b 54% (15)b
Cottage cheese 17% (10) 18% ( 5) 32% ( 9)
Other cheese 18% (ll) 14% ( 4) 18% ( 5)
Ice cream/ice milk 8% ( 5)C 25% ( 7)C 43% (12)

 

ln=60 These women died during or prior to 1972.
2n-28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers of subjects.
Letter pairs are significantly different, X2 2 3.841, p :_.05.

Total number of food records available for calculations:
Deceased in 1948 = 125
Survivors in 1948 56
Survivors in 1972 = 66

 

201

Table IV—6.--Amounts of Dairy Foods Consumed by Subjects in 1948 and

 

 

1972.*
l . 2 .
Food Pattern Deceased Suervors Suervors
1948 1948 1972
No fluid milk 17% (10) 28% ( 8) 14% ( 4)
§_l/4 cup milk/day 22% (13) 14% ( 4) 7% ( 2)
1/2 - 1 cup milk/day 47% (28) 43% (12) 57% (16)
> 1 cup milk/day 15% ( 9) 14% ( 4) 21% ( 6)
Milk as only dairy product 63% (38)a 36% (10)a 28% ( 8)
< 1/2 cup milk + other b b
dairy foods* 15% ( 9) 7% ( 2) 32% ( 9)
1 cup milk + other dairy c c
foods* 5% ( 3) 28% ( 8) 25% ( 7)
Other dairy foods only* 7% ( 4) 11% ( 3) 11% ( 3)
No milk or other dairy foods 10% ( 6) 18% ( 5) 4% ( 1)

 

*Excluding butter and cream.
ln=60 These women died during or prior to 1972.
2n=28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers of subjects.
Letter pairs are significantly different, x2 :_3.841, p :_.05.

Total number of food records available for calculations:
Deceased in 1948 = 125
Survivors in 1948 56
Survivors in 1972 66

202

both surveys, the survivors chose dairy foods other than
fluid milk, as reflected in the higher consumption levels
of cottage cheese and frozen desserts. Only one individual
in 1972 consumed no milk or other dairy food, compared to
the 11 women in the surviving group so categorized in 1948.

A majority of the subjects interviewed in both
years changed their pattern of milk and dairy food con-
sumption. Among the survivors, 10 (36%) increased their
intake of fluid milk between 1948 and 1972, whereas one-
half this number consumed less fluid milk in the latter
survey. Seven women who did not drink milk in 1948 did so
in 1972, with three of the seven consuming one cup or
more. Conversely, two subjects who drank one cup of milk
each day at the time of the initial survey, no longer drank
milk; another individual consuming three cups milk each
day in 1948, used less than one cup in 1972. Of the 13
women who did not change their intake of this food over
the 24-year interval, nine consumed 1/2 to 1 cup milk each
day.

In addition to changes noted in the use of fluid
Inilk between 1948 and 1972, differences were evident in
the selection of other dairy foods (Table IV-5). Five
subjects who used cottage cheese in 1972 did not choose
this itemnin 1948, while one subject deleted this food from

her diet” Three women eliminated ice cream as a dessert

 

203

between 1948 and 1972, whereas seven subjects selected ice

milk in 1972.

Bread, Cereal and Baked Products.--The consumption

 

frequencies of bread, cereal and sweet baked products
(Table IV-7) suggest a change in the nutrient density of
the items selected. Use of white and "whole wheat" bread
changed but slightly, whereas more of the survivors now
include cereal in their diets. Specialty rolls (for
frankfurters and hamburgers) appeared more frequently in
the 1972 dietary records. In contrast, the survivors
including cake in their diets decreased from 64 percent in
1948, to 25 percent in 1972, a significant difference.
Similarly, fewer subjects consumed pastry, although cookies

were in 1972 a popular dessert.

The daily servings of bread, cereal and baked
products can be seen in Table IV-8. In 1972, as compared
with 1948, several subjects decreased their use of bread.
Only 11 women, or 40 percent, consumed more than two
slices of bread each day in 1972, although 15 (53%) did
so in 1948; however, this difference was not significant.
Alternatively, 55 percent of the deceased included more
than two slices of bread in their daily meal pattern.

In 1972, sweet baked products appeared less fre-
quently in the diets than was the case in 1948 for both
survivors and deceased. No subject in 1972 had more than

two servings of sweet baked products daily, in contrast

204

Table IV-7.-—Bread and Cereal Products Chosen by Subjects
in 1948 and 1972.

 

 

Deceasedl Survivors2 Survivors
F°°d Item 1948 1948 1972

White bread 70% (42) 64% (18) 61% (17)
"Whole wheat" bread 27% (16) 36% (10) 39% (11)
Breakfast cereal 50% (30) 46% (13) 68% (19)
Rice 2% ( 1) 7% ( 2) 14% ( 4)
Pasta 12% ( 7) 14% ( 4) 21% ( 6)
Crackers 25% (15) 18% ( 5) 28% ( 8)
Rolls 5% ( 3) 11% ( 3)a 39% (11)a
Cake 48% (29) 64% (18)b 25% ( 7)b
Cookies 42% (25) 39% (11) 46% (13)
Pastry 23% (14) 21% ( 6) 11% ( 3)

 

ln=60 These women died during or prior to 1972.

2n=28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers of subjects.
Letter pairs are significantly different, x 3 3.841,
p i .05.

Total number of food records available for calculations:

Deceased in 1948 = 125
Survivors in 1948 = 56
Survivors in 1972 = 66

 

205

Table IV-8.--Amounts of Bread and Cereal Products Consumed by Subjects
in 1948 and 1972.

 

 

Food Pattern Deceasedl Survivors2 Survivors
1948 1948 1972

1-2 slices bread/day 42% (25) 46% (13) 61% (17)
3-4 slices bread/day 45% (27) 46% (13) 36% (10)
:_5 slices bread/day 10% ( 6) 7% ( 2) 4% ( 1)
1-2 sweet baked products/day 58% (35) 61% (17) 57% (16)
:_3 sweet baked products/day 18% (ll) 7% ( 2) 0% ( O)
No sweet baked products 23% (14) 32% ( 9) 43% (12)
:_l cereal/day 50% (30) 46% (13) 68% (19)
2 servings bread-cereals/day 7% ( 4) 11% ( 3) 7% ( 2)
3-5 servings bread-cereals/day 45% (27) 54% (15) 71% (20)
3.6 servings bread-cereals/day 47% (28) 36% (10) 21% ( 6)

 

1n=60 These women died during or prior to 1972.

2n=28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers of subjects. There were
no significant differences.

Total number of food records available for calculations:

Deceased in 1948 = 125
Survivors in 1948 = 56
Survivors in 1972 = 66

 

206

to nearly one-fifth of the deceased. Twelve of the sur-
vivors had no "high sucrose" baked dessert on any of the
recorded days in 1972. The total number of daily servings
of bread, cereal and baked products tended to be higher
among all subjects in 1948, reflecting the increased
intake of carbohydrate calories at that time.

Changes in the pattern of consumption of cereals
and baked products noted among various individuals, sug—
gest differences in both the quantity and quality of
selections. Eighteen or 64 percent of the survivors
included approximately the same number of servings from
this food category in their diets in 1972 as in 1948;
however, the specific items differed. Baked products,
high in sucrose, were less frequent, being replaced by
crackers or breakfast cereals. Conversely, three women
who consumed only two servings of cereal or baked products
in 1948 increased their intake, with two of the three
adding a sweet baked product to the daily pattern. The
third subject consumed in 1972 more than six servings each
day, having added bread or specialty rolls and a sweet
dessert. Of the seven women who decreased their use of
cereal and baked products, five deleted high-calorie
sweets. One subject, who in 1948 consumed three pieces
of pie in one day, had no sweet baked product on any day
for which records were available in 1972. Four women

d§$creased.their intakes of bread.

I!

 

207

Sugar and Concentrated Sweets.--Sugar intakes among

 

the Lansing women decreased significantly between 1948 and
1972 (Table IV-9). In the latter year, 15 of the 28
survivors used no sugar as such, and 11 of these avoided
other concentrated sweets as jam, candy or syrup. This
was true for only six and three of the survivors,
respectively, in 1948. Contrary to this finding, 12 women
(43%) used slight amounts of jam or jelly (one teaSpoon

to one tablespoon) on bread or toast in 1972 compared with
only five in 1948. Five individuals (18%) reported in
1972, intakes of candy, usually consisting of several hard
peppermints or a few gum drops; only one individual had a
piece of chocolate. A lesser number of the survivors
(14%) included candy in their diets in 1948, although one
woman consumed this food in both years. Of the 12 survi—
vors using jam or jelly in 1972, only one listed this
confection in the previous survey. As to the use of
alcoholic beverages, one deceased subject had a bottle of
beer when surveyed in 1948, whereas one survivor in 1972
had one highball each evening.

There was, however, a marked difference in the
amount of sugar, as such, consumed by survivors and
deceased. At the time of the initial survey, only one-
fifth of the deceased consumed no sugar, while one—half
had at least two tablespoons daily. Of the deceased, one

flad six and another nine tablespoons of sugar each day.

 

208

Table IV-9.--Sugars and Sweets Chosen by Subjects in 1948 and 1972.

 

 

1 . 2 .
Food Item Deceased Suervors Suervors
1948 1948 1972

Jam or jelly 10% ( 6) 18% ( 5)a 43% (12)a

Table syrups* 7% ( 4) 14% ( 4) 14% ( 4)

Candy 5% ( 3) 14% ( 4) 18% ( 5)
b b

No sugar 22% (13) 21% ( 6) 54% (15)
c c,d d

5'1 tablespoon sugar 28% (17) 68% (19) 39% (11)

2-3 tablespoons sugar 43% (26)e 11% ( 3)e O ( O)

:_4 tablespoons sugar 7% ( 4) O ( O) 7% ( 2)

 

*Chocolate syrup, corn syrup or molasses.

1n=60 These women died during or prior to 1972.

2n=28 These women were interviewed in 1948 and 1972.

Numbers in parentheses are actual numbers of subjects.
Letter pairs are significantly different, X2 Z_3.84l, p E_.05.

Total number of food records available for calculations:
Deceased in 1948 = 125
Survivors in 1948 56
Survivors in 1972 = 66

 

209

In contrast, only 11 percent of the survivors in 1948 had
daily intakes of sugar above two tablespoons. By 1972,

the majority of this group had deleted sugar as such from
their diets, using artificial sweeteners for flavoring
coffee, tea or cereal. The two survivors who in 1972 con-
sumed four and six tablespoons of sugar daily, respectively,
have doubled their intake since 1948. These women, aged

73 and 90 years, sprinkle sugar on their bread. Eleven of
the 19 survivors have continued intakes of one tablespoon
or less of sugar each day, whereas eight of those so cate-

gorized in 1948 no longer use sugar.

Animal and Vegetable Fats.--Both the kind and

 

quantity of fats consumed by the Lansing women changed
from 1948 to 1972. As shown in Table IV—10, 62 and 78 per-
cent of the deceased and survivors, respectively, used
butter in 1948, although only 25 percent of the survivors
continued to use this fat in 1972; a significant decline.
Conversely, 18 percent of the survivors chose margarine in
the initial survey, whereas 61 percent used this table fat
in 1972. Four of the survivors used no table fat in 1972,
as compared with only one from that group in 1948. Of the
five survivors who previously chose margarine, one changed
to butter, and one has deleted table fat. Two women who in
1972 consumed no table fat formerly used butter, whereas

one survivor used neither butter nor margarine in either

Study.

 

 

 

 

210

Table IV-10.--Animal and Vegetable Fats Chosen by Subjects
in 1948 and 1972.

 

 

Food Item Deigizedl Surgigorsz Surgigors
Butter 62% (37) 78% (22)a 25% ( 7)a
Margarine 32% (19) 18% ( 5)b 61% (17)b
Cream 62% (37) 43% (12)C 4% ( 1)C
Bacon 17% (10) 11% ( 3) 18% ( 5)
Peanut butter 7% ( 4) 11% ( 3) 0 ( 0)
Fried foods 88% (53) 82% (23)d 46% (l3)d
No table fat* 7% ( 4) 4% ( 1) 14% ( 4)
3 1 T table fat 13% ( 8) 21% ( 6)e 78% (22)e
2 T table fat 48% (29) 54% (15)f 4% ( 1)f
3 T table fat 10% ( 6) 11% ( 3) 4% ( l)
3 4 T table fat 22% (13) 11% ( 3) 0 ( 0)

 

*Butter or margarine.

1n=60 These women died during or prior to 1972.

2n=28 These women were interviewed in 1948 and 1972.
Numbers in parentheses are actual numbers of subjects.
Letter pairs are significantly different, x 3 3.841,

p i .05.

Total number of food records available for calculations:

Deceased in 1948 = 125
Survivors in 1948 = 56
Survivors in 1972 = 66

 

211

Similarly, the quantity of table fats consumed has
significantly decreased (Table IV-lO). Although 76 per-
cent of the survivors consumed more than one tablespoon of
butter or margarine daily in 1948, this was true for only
8 percent in 1972.

Observed changes in the use of condiments high in
fat revealed a less consistent trend. Although a majority
of the women interviewed in 1948 included cream (or half
and half) in their daily meal pattern, only one subject in
1972 reported use of this dairy product. Two others who
previously used cream, reported using a "non-dairy"
coffee whitener in 1972. Despite the decline in con-
sumption of high-fat dairy items, bacon was included more
frequently in the menus of the survivors in 1972, than in
1948.

Inasmuch as salads and fresh vegetables were popu-
lar among many survivors in 1972, salad dressings made
from vegetable oil appeared on the food records of eight
subjects with two others including commercial "low-calorie"
salad dressings. Six survivors used mayonnaise when
studied in 1948 compared with one in 1972. A striking
difference in the consumption of fats is reflected in the
significant change in use of this method of food prepara-
tion. In 1948, 23 of the survivors (82%) consumed at least

one fried food. This was true for only 13 (46%) in 1972.

 

212

Discussion

 

It is difficult to arrive at a valid explanation(s)
for the changes in food patterns of the Lansing women over
the period 1948 to 1972. A number of factors may be
involved therein. The more obvious is that the trends
reflect alterations in the tastes of women as they age.
That may not be the only factor since there have been
prominent alterations in the availability of different
foods during the 24-year interval. These changes involve
both fresh and "processed" foods of which frozen foods are
the best example. Similarly food varieties commonly used
in 1972 as ice milk (frozen dessert) and milk with 2
percent fat content, were virtually unknown in 1948. Such
differences in food availability have produced changes in
the dietary patterns of all age groups over this period.
The alterations in the food habits of the Lansing women
which occurred between 1948 and 1972 will be examined in
respect to the advancing age of these individuals as well

as national trends reflected in persons of all ages.

Food Selection and Nutrient Intake.--The signifi-
cant differences in the nutrient intakes of the survivors
between 1948 and 1972, and between survivors and deceased
in 1948, can be related to the food selection patterns of
each group of women. Protein intakes in 1948 were lower
among those now deceased, in that one-fifth of this group

did not have a serving of meat or egg each day. This

’7

213

value compares favorably with the findings of Jordan and
associates (1954) who reported that 34 percent of their
aged subjects in Westchester County, New York, had less
than one serving of meat, fish or poultry each day.
Inasmuch as the deceased Lansing subjects were, at the
time of the initial survey, primarily of retirement age,
economic limitations may be responsible in part for their
lowered protein intake. Although the survivors were
older in 1972 than were the deceased in 1948, they con-
tinued to have generous servings of animal protein. The
emphasis placed upon protein nutrition by the popular
press, may have contributed to the selection patterns
observed among the survivors. Alternatively, one might
question whether the higher protein intakes of the younger
subjects has contributed to their survival.

A second nutrient differing in quantity in the
diets of both groups of women in 1948 was ascorbic acid.
'This is confirmed by the fact that only 42 percent of the
deceased consumed a citrus fruit on at least one day for
which food records were available, contrasted with 78 per-
cent of the survivors. Intakes of ascorbic acid have

:remained high among survivors over the 24—year interval.

Food Selection as Related to Age.--Advancing age
laas been reported to be associated with a reduction in
‘meat.consumption. Davidson and coworkers (1962) stated

that one-half of their 104 apparently healthy Bostonians

214

over 50 years of age, had lowered their intakes of meat.
Those authors suggest this change to be the consequence of
living alone, diminished income or "aging." No subject in
that study confessed to lowered meat intake as a result of
difficulty with chewing. Inasmuch as problems with dentition
can influence meat choices, this variable was examined in
regard to the deceased Lansing subjects. Although 11 of

the 60 deceased Lansing women reported problems with "sore
mouth or gums," this symptom was not related to the intake

of animal, plant or total protein.

Increasing age, per se, has not caused a diminution
in protein intake among the Lansing survivors. As these
women have become older, their servings of meat, fish and
eggs, have in some cases, actually increased. Fish, chosen
by 25 percent of the survivors in 1948, was noted on the
food records of 36 percent of this group when examined in
1972. Eggs have also increased in popularity, being con-
sumed by 64 percent of the survivors as an addition to at
least one serving of meat. The high percentage of the
survivors consuming eggs in 1972 is surprising, in view of
the widespread publicity given to the effect eggs are
reported to have on serum cholesterol levels, and the
relation of the latter to cardiovascular disease. The
Lansing women were similar, in this respect, to aged

Britishers. Exton-Smith (1972) observed that 879 English

l!

215

subjects above 65 years of age maintained their pattern of
egg consumption, despite advancing age. According to that
author, older individuals tend to eat more eggs than does
the population as a whole. Among the aged Bostonians
(Davidson et al., 1962), changes in consumption patterns
were not consistent, as 16 percent were eating eggs more
frequently than before, and 30 percent avoided eggs for
health reasons. For the others, no change was recorded.

Additional evidence suggesting that protein intake
does not always decrease with age, comes from a study of
older households in Rochester, New York (LeBovit and Baker,
1965). At that time, 96 percent of the household units
reported at least one serving of meat daily (poultry and
fish were excluded); this value was only slightly less
(91%) among females residing alone. One factor to be con-
sidered in relation to these data is that each subject
completed dietary records for seven days. Despite the
extended period for which records were available, liver or
a liver product, was consumed at least once by only 14
'percent of the Rochester respondents as compared with 18
percent of the Lansing women interviewed in 1972; in the
latter cases, the dietary records included a period of
one to eight days.

Several investigators (Jordan et al., 1954;
Davidson et al., 1962; LeBovit and Baker, 1965) have noted

the low consumption of milk or dairy (calcium) equivalents

216

among older subjects. Forty-three percent of the aged
individuals interviewed in Westchester County, New York
(Jordan et al., 1954) had less than a pint of milk or
its equivalent each day. In comparison, 39 percent of the
deceased subjects when examined in 1948, and 43 and 21
percent, respectively, of the survivors in 1948 and 1972,
consumed less than one cup of milk daily. Older women
living alone in Rochester (LeBovit and Baker, 1965) used
the equivalent of 3.7 quarts of milk per week, or approxi-
mately one pint per day. One-fourth of the Bostonians
studied by Davidson and coworkers (1962) reported increased
milk consumption in their fifth, sixth and seventh decades;
however, an equal number were drinking less milk than
formerly. As to changes in milk consumption within the
Lansing subjects, ten survivors consumed more fluid milk
in 1972 as compared with 1948, and five, less. Among the
Lansing women, milk consumption was closely related to the
use of breakfast cereals.

The decrement in dietary calories and fat among the
Lansing survivors in 1972 may be explained, in part, by
their selection of specific dairy products. While only
one subject in 1948 used a low-fat milk, 54 percent of
those interviewed in 1972 use either skimmed or low-fat
milk. This finding may be compared with the 27 older
families in Everett, Washington (Van Syckle, 1957), none

of whom selected skim milk. Alternatively, 14 percent of

217

the Boston subjects (Davidson et al., 1962) and 11 percent
of the Rochester families (LeBovit and Baker, 1965) were
using low—fat milk. Similarly, cream, selected by 62 and
43 percent of the deceased and survivors, respectively, in
1948, was noted on 44 percent of the diet records obtained
in Everett, Washington (Van Syckle, 1957), but on only

15 percent of those from older households in Rochester,
New York (LeBovit and Baker, 1965).

Exton-Smith and Stanton (1965) reported that for 60
aged women living alone in London, cheese was not a pOpular
food, despite the fact that it was a cheaper source of
protein than meat or eggs, and could be stored easily.
Cheese was consumed by less than one-third of the London
women. According to those subjects, cheese was indiges-
tible and caused constipation. In 1972, cottage cheese
was consumed regularly by nearly one-third of the Lansing
survivors, although only 18 percent of those interviewed
consumed other varieties of cheese. Contrary to the find-
ings of Exton-Smith and Stanton (1965), however, no
particular reasons were given by the Lansing women for
either selecting or avoiding cheese foods.

Vegetables and fruits may be deleted from the diets
of older subjects as a result of digestive disturbance or
intestinal disease. The foods most consistently omitted
from the diets of older subjects studied by Jordan and

associates (1954) were dark green and yellow vegetables.

218

Items from this food group were consumed by only 41 percent
of those subjects (Jordan et al., 1954). A similar situ-
ation existed among the older people living at home,
studied by Lyons and Trulson (1956). Thirty-five percent
of the men and 41 percent of the women selected a vege-
table providing adequate levels of vitamin A. Similarly,
in the Lansing study, only 23 percent of the deceased sub-
jects consumed, on at least one day, a dark green or deep
yellow vegetable or fruit. In contrast, 64 percent of the
survivors chose one of these foods when queried in 1972;

an observation which explains, in part, the high mean
intake of vitamin A. Survivors in 1972 frequently
mentioned their concern for selecting "balanced diets" and
the need for including specific types of vegetables and
fruits. This awareness of nutritive needs could contribute
to the increased selection of vitamin A-rich vegetables

and fruits.

A significant difference existed between the
numbers of deceased and survivors who included a citrus
fruit in their diets in 1948. Only 42 percent of the
deceased had such a fruit in their meal plan as compared
with 78 percent of the survivors. As a result, dietary
levels of ascorbic acid were significantly higher among the
latter. By comparison, 62 percent of 245 Minnesota home-
'makers (mean age = 43 years) interviewed in 1948 (Clark and

Fincher, 1954) had a citrus food on the day studied. The

219

slight decrease in consumption of vitamin C-rich fruits by
survivors between 1948 and 1972 may relate to the avoidance
of acid foods by several subjects now under treatment for
diverticular disease. Potatoes, a potentially good source
of ascorbic acid, were consumed by 75 percent of the sur—
vivors in 1972. That number is similar to the 82 percent
of older households in Rochester, New York (LeBovit and
Baker, 1965), who included potatoes in their diet pattern.

Information from both the 1948 and 1972 food
records suggest that older subjects consume adequate
levels of fortified bread and cereals. Further evidence to
support this finding comes from the aged populations in
Westchester County, New York (Jordan et al., 1954), and
and Boston (Lyons and Trulson, 1956), as only one of the
200 persons interviewed failed to have at least one serving
daily of an enriched or whole grain bread or cereal. Only
one Lansing subject interviewed in 1972 failed to include
one slice of bread in her dietary; however, she did con—
sume one serving of cereal plus a sweet roll.

There is a popular generalization that older indi-
viduals consume higher levels of starches and sweets than
does the general population. As suggested by Jordan et a1.
(1954), aged subjects do not always use these items in
excess, for desserts, as cake or pie, were omitted from
the dietaries of 37 percent of those studied in Westchester,

New York. That finding is supported by the Lansing results

220

indicating that two-fifths of the survivors, when examined
in 1972, had no sweet baked dessert on any of the recorded
days.

In contrast to the decline in consumption levels
of high-sucrose desserts, the use of jam and jelly has
increased since 1948. More than twice the number of sur—
vivors in 1972 included fruit preserves in their diets
compared with 1948. Among these subjects such "sweets"
were used as a substitute for butter or margarine, thereby
decreasing the total intake of fat. Although fewer women
included jam or jelly in their diets in 1948, butter and
margarine were used in more liberal amounts. Health
reasons (i.e., digestive disturbance, weight control) were
cited as motivating factors in decreasing consumption of

fat.

Food Selection as Related to
Food Availability

The changes in the nutrient intake of the Lansing
subjects between 1948 and 1972 may relate, in part, to
their increasing age; however, there have also been changes
in food availability over this period, modifying the food
habits of the population as a whole. The higher intakes
of animal foods (meat and egg servings) by the surviving
Lansing women in 1948 may partially reflect the general
trend in the United States. According to USDA market

surveys (Swope, 1970), animal foods provided only one-half

221

of the total protein intake in 1909, compared with two-
thirds in 1965. The survivors, being younger in age,

might have responded to this trend to a greater degree
than the older women who are now deceased. As mentioned
previously, the reduced financial resources of the older
retired subjects, may have limited their purchases of meat.
The level of consumption of meat (including fish or poultry)
by the Lansing women in 1948 was similar to that reported
in a USDA study of homemakers in a North Central community
(Clark and Fincher, 1954). Whereas 80 percent of the
deceased Lansing subjects and 100 percent of the survivors
had in 1948 at least one serving of meat or egg each day,
90 percent of the Minnesota homemakers, studied in the
same year, consumed at least one of these animal foods on
the day surveyed.

Current controversy regarding a possible relation
between dietary cholesterol and arterial disorders has
drawn attention to the inclusion of eggs in the diet.
One-half of the Minnesota homemakers (Clark and Fincher,
1954) consumed an egg on the day of the survey in 1948.
This value is equal to that noted among the Lansing sub-
jects in that year. In contrast to the general population,
the Lansing survivors, during the next quarter century,
actually increased their use of this food. USDA house-

hold surveys (Swope, 1970) revealed that eggs were used

222

less frequently by the general population in 1965 than had
been true ten years prior.

Differences were observed in the varieties of meat
chosen by the survivors in 1948 and 1972. Beef was a
choice of 57 percent of the survivors in 1948, a value
higher than that noted among Minnesota women (Clark and
Fincher, 1954) interviewed in 1948, as only 38 percent
consumed beef on the day surveyed. One factor that must
be considered in the comparison of the Lansing subjects
and the Minnesota women (Clark and Fincher, 1954) is the
number of days for which records were available. The
Minnesota women provided a 24-hour recall on one day only,
whereas 181 food records were available for the 88 Lansing
subjects. This may explain, in part, the difference in
beef consumption observed between the Minnesota and Lansing
subjects.

Beef has increased in popularity in the North
Central region (U.S. Dept. of Agriculture, 1968) as evi-
denced by a 22 percent increase in the use of this meat
by households surveyed in 1955 and 1965. This change is
reflected in the number of survivors choosing beef in
1948 and 1972 (57 versus 64%), although this difference
was not significant. Another trend observed among North
Central households between 1955 and 1965 (U.S. Dept. of
Agriculture, 1968) was a 27 percent increase in the use of

chicken, although only a slight change (4%) was noted among

223

the Lansing survivors. This difference could relate to
the fact that USDA household consumption surveys are based
upon 7-day records, as compared with an average of two days
for the Lansing women.

Fish was consumed more frequently by Lansing women
in 1948 than by other North Central homemakers. Twenty
and 25 percent, respectively, of the deceased and survivors
had fish on at least one day, compared with only 11 percent
of the Minnesota subjects (Clark and Fincher, 1954).
Although the use of fish dropped by 15 percent in the
North Central region between 1955 and 1965 (U.S. Dept. of
Agriculture, 1968), this food was found in the diets of
36 percent of the survivors in 1972, compared with only
25 percent in 1948. As to the use of specialty meats,
21 percent of the survivors included weiners in their
meals in 1972; this value is only one-half that noted in
other North Central households, 45 percent of whom used
this food in 1965 (U.S. Dept. of Agriculture, 1968).

Milk was not a popular food among the Lansing
women in either 1948 or 1972. When examined in 1948, 83
percent of the deceased had some fluid milk as compared
with only 71 percent of the survivors and 72 percent of
other North Central women (Clark and Fincher, 1954). The
consumption of fluid milk has, however, increased among

the survivors from 1948 to 1972, despite an 18 percent

224

decline in use of this food among North Central families
(U.S. Dept. of Agriculture, 1968).

Other changes in the types of dairy foods chosen by
survivors, however, do parallel trends observed among the
North Central population. Household surveys (U.S. Dept. of
Agriculture, 1968) suggest that use of non-fat dry milk
doubled between 1955 and 1965. The Lansing survivors also
have substituted low-fat varieties of milk for those
higher in calories. Similarly, cream is purchased less
frequently, and cheese and frozen milk desserts more fre-
quently, by both the Lansing subjects in 1972 and the
general population in 1965 (U.S. Dept. of Agriculture,
1968), as compared with 1955. Ice milk, a popular choice
among the survivors in 1972, was not generally available
for consumer purchase at the time of the initial survey.
These changes in dairy items selected in both Lansing and
a cross-section of United States households, could reflect
a voluntary restriction on calories and fat. Another
factor may be that of economy, with the substitution of
milk for cream in coffee.

The pattern of consumption of fruits and vege-
tables by the Lansing subjects in 1948 differed from that
of other North Central women. Sixty-two percent of Minne-
sota homemakers interviewed that year (Clark and Fincher,
1954) had a citrus food on the day surveyed, compared with

42 and 78 percent of the Lansing deceased and survivors,

225

respectively, who had this food on at least one day for
which records were available. Although only 23 and 36
percent of the two subject groups in Lansing reported a
vitamin A source in 1948, 69 percent of the women in
another North Central study (Clark and Fincher, 1954) did
so. Conversely, potatoes were more popular among the
Lansing subjects. In comparing these data, the influence
of seasonal differences is difficult to measure, as the
Minneapolis women were studied in winter when fresh produce
was less likely to be available. In contrast, many of the
Lansing women, who demonstrated lower intakes of fruits
and vegetables, were interviewed during the winter, spring
and early summer in 1948.

According to a USDA survey of North Central house-
holds in 1965 (U.S. Dept. of Agriculture, 1972), the quan-
tity of fresh fruits and vegetables consumed and the money
spent per household for these items changed dramatically
from one season of the year to another. These changes were
not always consistent. Use of fresh vegetables was two-
fold in the summer, as compared with other seasons of the
year; however, the consumption of dark green and deep
yellow vegetables varied less than 10 percent over this
time period. Fresh tomatoes appeared to be the vegetable
Showing the greatest fluctuation over the calendar year.
Although fresh fruit was purchased in greatest quantity

during the summer season, this was not true of citrus

226

varieties. Contrary to what might have been anticipated,
household consumption of citrus fruits was increased three—
fold in the winter as compared with the summer. As expected,
the money spent for fresh produce was highest during the
summer months. One factor to be considered with these data
is a possible difference between the time when these items
were purchased and the date when eaten. Fresh produce may
be canned or frozen for use in a later season.

Over the past 24 years, the use of fruits by the
Lansing survivors has remained constant, whereas deep green
and yellow vegetables are included in the diet more fre—
quently. This has not been true of other households in
the North Central region. Between 1955 and 1965 (U.S.
Dept. of Agriculture, 1968), the consumption of all fruits
declined by 15 percent with a concomitant reduction of 6
percent in the ascorbic acid available to each person in
the household (Swope, 1970). Although potatoes were used
less frequently by North Central households in 1965 than
ten years prior, this food remained popular among the
Lansing survivors. The 10 percent decline in the con-
sumption of all vegetables by North Central families
between 1955 and 1965 (U.S. Dept. of Agriculture, 1968)
resulted in lowered vitamin A intake, whereas the Lansing
women actually increased their selection of vitamin A-
rich produce. The continued use of potatoes by the

Lansing subjects may reflect long-established food habits

227

among older individuals. The selection of fruits and vege-
tables high in nutrients, however, in contrast to general
trends, may indicate a conscious effort toward good
nutrition. In the dietary interview in 1972, subjects fre-
quently noted choosing foods that constituted "a well-
balanced diet."

The Lansing women have continued to consume rather
generous levels of bread each day, although use of this
food declined by 8 percent among the population as a whole
(Swope, 1970). In contrast, the consumption of other
bakery products, including sweet confections, increased by
66 percent in the North Central region from 1955 to 1965
(U.S. Dept. of Agriculture, 1968). Although the older
Lansing women significantly increased their use of rolls,
which could relate to the recent popularity of weiners
and hamburgers among all age groups, they severely curtailed
their consumption of sweet products. Restricted intake
of baked items high in sugar and fat was frequently cited
as a factor in weight control among the Lansing subjects.
Breakfast cereals which have increased in popularity,
nationwide, were noted more frequently in the 1972 diets
than in those of either group in 1948.

’ The diets of the Lansing survivors reflect both
national and regional trends in the use of animal and
vegetable fats. Although 79 percent of the survivors

used butter in 1948, this value had dropped to 25 percent

228

by 1972. A lesser decline in the use of butter, 34 per-
cent, was noted in the North Central region between 1955
and 1965 (U.S. Dept. of Agriculture, 1968), according to
household food consumption data. In reciprocal fashion,
margarine has been added to the diet. Sixty-nine percent
of North Central households surveyed in 1965 (U.S. Dept.
of Agriculture, 1968) reported using margarine, a value
comparable to that observed (61%) among the Lansing sur-
vivors.

The use of fats and oils has, during the past 24
years, changed both qualitatively and quantitatively. As
the Lansing survivors have significantly decreased their
consumption of visible fat, so did other households in the
North Central region (U.S. Dept. of Agriculture, 1968),
although to a lesser degree (10%). Shortening and lard are
now used in significantly lower amounts by North Central
families, whereas the consumption of salad and cooking oils
doubled between 1955 and 1965 (U.S. Dept. of Agriculture,
1968). The shift of the population to oils, however, did
not totally compensate for the shift away from fats. The
general rise in household use of cooking oils could relate,
in part, to preparation of fried foods. Significantly
fewer items prepared by this method were noted on the diet
records of the survivors in 1972 as compared with 1948
(82 versus 46%). Many subjects avoided fried foods on the

advice of their physicians, as a result of occurring

229

distention or gall bladder insufficiency. As an alter-
native, meats were frequently broiled.

One factor contributing to the per capita con-
sumption of fat has been the growth of the fast-food
industry which concentrates heavily upon fried items.

Three of the survivors, interviewed in 1972, obtained at
least one meal during the period of record at a fast-food
restaurant. This would suggest that older individuals do
accept new forms of food delivery, if applicable to their
circumstances.

Sugar substitutes or artificial sweeteners are
becoming increasingly popular among all groups in the gen—
eral population. This is suggested by recent household
consumption data (U.S. Dept. of Agriculture, 1968) indi-
cating that dietary intakes of sucrose in the form of
sugar, jelly and jam, decreased by nearly 15 percent in the
North Central region between 1955 and 1965. The findings
pertaining to the ingestion of sugar among the Lansing
survivors in 1972 are, for the most part, consistent with
the regional trend. Over one-half of these women consumed
no visible sugar. This was true for only 21 percent of the
survivors when surveyed in 1948. The two survivors who
did in 1972 consume at least four tablespoons of sugar each
day, sprinkle this sweetener on their bread. In contrast
to the general population, the number of Lansing subjects

‘who have added jam or jelly to their diets has increased

230

dramatically. For several women who severely restrict their
intakes of fat, jam or jelly is being used as a substitute

for butter and margarine on bread or toast.

Conclusions

 

Personal food habits can and do change from_middle
to older age. Despite advancing years, the surviving
subjects have increased their consumption of animal pro-
tein, low-fat varieties of milk and frozen desserts, with
a changeover from animal to vegetable fats. Such trends
have also been observed among the general population. In
contrast to the national trends, these women have increased
their use of eggs and vitamin A-rich fruits and vege-
tables, have continued to choose bread and cereals, and
actually decreased their intakes of sweet baked products
as cake or pie, sugars, and fats.

Motivation toward the maintenance of good health
or limitations imposed by physical disorders and weight
control, may contribute to these observed choices. Spon—
taneous alterations in food selection as the increased
consumption of foods high in protein or ascorbic acid, may

reflect increased consciousness of nutrient factors.

CHAPTER V

INFLUENCE OF NUTRIENT INTAKE UPON CLINICAL

AND BIOCHEMICAL PARAMETERS IN OLDER WOMEN

Introduction

 

In recent years the conquest of infectious diseases
has markedly increased the lifespan. There are now in this
country, 8.4 million males and 11.6 million females over
the age of 65 years (U.S. Bureau of Census, 1973, p. 31).
Many factors determine the health and longevity of older
pe0p1e. PrOper nutrition throughout life has been suggested
as one of the best means of minimizing the degenerative
changes and superimposed diseases frequently associated with
old age (Irwin, 1970). One's nutritional status thus looms
as an important component of life which may have far-
reaching effects on both morbidity and mortality.

The evaluation of nutritional status in the elderly
is difficult, in that little is known regarding possible
alternations in nutrient requirements as a result of the
progression from middle to advanced age. For the latter
group, there is only limited information about the bio-
chemical parameters frequently employed to measure nutriture.

As to vitamin status, studies of 577 persons over 50 years

231

232

of age in San Mateo, California (Gillum et al., 1955a;
Morgan et al., 1955), the population of Groton Township,
New York (Williams et al., 1951), and the aged in Onondago
County, New York (Brin et al., 1965), revealed no signifi-
cant change in serum levels or urinary excretion as a
function of age.

One complication in assessing the nutritional
status of older peOple is the fact that some symptoms
associated with nutrient deficiency may be a general
accompaniment of old age. For example, Gillum and
associates (1955a) concluded that the thickening of the
bulbar conjunctiva, identified in 94 percent of 569 aging
subjects, was a consequence of aging rather than a
deficiency of vitamin A. This observation suggests that

the anatomy of aging is not well understood.

To further investigate the relation between nutrient

intake, clinical symptoms, biochemical parameters and
physical health in older persons, the author re-examined
cooperating survivors of a sample of 103 women from Lansing,
Michigan, previously studied by Ohlson and coworkers
(1950, 1951, 1952, 1952a) in 1948 when the subjects ranged

in age from 40 to 88 years.

Methods
Procedures of sample selection and data collection
in 1948 (Chapter II, pp. 92-93) and re-examination in 1972

(Chapter II, pp. 93-95) have been described previously.

233

For clinical and biochemical evaluation, subjects were
admitted to Olin Health Center, Michigan State University,
in the evening (Protocol, Appendix D-l). A dentist per—
formed an oral examination (Appendix D-2) that evening.
Blood was drawn the next morning following a 12 hour

fast. In Table V-l are listed the biochemical analyses
applied to the fasting blood sample, as well as the
laboratory where each was performed. Aliquots of serum for
the determination of vitamin A and 8 carotene levels, and
serum iron and iron-binding capacity, were immediately
frozen and stored at —40°C. Blood to be analysed for iron
was handled in acid—washed glassware. For ascorbic acid
analysis, serum aliquots were precipitated with trich-
loroacetic acid (TCA) and the TCA filtrate, similarly
frozen.

The first urine voided upon arising in the morning
was collected in a clean, dry container, evaluated in terms
of color and volume (Appendix D-3), protected from light,
and refrigerated. As shown in Table V—2, standard
urinalyses included tests for pH, Specific gravity, glucose,
ketones, protein, and occult blood. Following acidifi-
cation with 0.1N HCl (ICNND, 1963), suitable aliquots were
stored at.-40°C for vitamin, creatinine, urea nitrogen and
total nitrogen determinations.

Those individuals who would not come to the Health
Center the evening before testing were directed to fast

following their evening meal, and were transported to the

234

Table V-l.--Biochemical Methods of Blood Analysis.

 

Whole Blood--Fasting

 

Hemoglobina

Hematocrita

Red blood cell counta
White blood cell counta
Mean cell volumea
Mean cell hemoglobina

Mean corpuscular hemoglobin concentrationa

Blood Serum--Fasting
b

 

Glucose
Cholesterolb

Calciumb
Phosphorusb
Total proteinb
Albuminb
Blood urea nitrogenb
SGOTb

Alkaline phosphatase
b

b
Bilirubin
Uric acidb

Lactic acid dehydrogenaseb
Vitamin AC (Neeld and Pearson, ICNND, 1963)

8 caroteneC (Neeld and Pearson, ICNND, 1963)
Ascorbic acidc (Roe, Vitamins, Vol. VII, 1967)

Serum iron and iron-binding capacityc (Caraway, 1963)
InsulinC (Amersham/Searle, 1969)

Blood Serum--Post prandial

Glucosea

InsulinC (Amersham/Searle, 1969)

_¥

. aPerformed by Olin Health Center Clinical Laboratory,
Michigan State University.

bPerformed on the Autoanalyzer 12/60, Technicon

Cerp., by the Mid-Michigan Clinical Laboratory, Lansing,
Mlchigan.

cPerformed by the author.

235

Table V-2.--Biochemical Methods of Urine Analysis.

 

Urine--Fasting

 

Routine urinalysis

Specific gravitya

pHa
Presence: glucosea (Bili-Lab Stix)
ketonesa (Bili-Lab Stix)
proteina (Bili-Lab Stix)
occult blooda (Bili-Lab Stix)
Thiaminb (Leveille, 1972)
RiboflavinC (Pelletier and Madine, 1970)

Ureab (Phenol-Hypochlorite method, Hyland Laboratory,
Costa Mesa, California)

Total nitrogenb (Kjeldahl method)
b (Alkaline picrate method, modified by
Olin Health Center Clinical Laboratory,
Michigan State University)

Creatinine

Urine—-Post¥pandial

 

Presence: glucosea (Bili—Lab Stix)

a

ketones (Bill-Lab Stix)

 

aPerformed by Olin Health Center Clinical Labora-
tory, Michigan State University.

bPerformed by the author.

CPerformed on Technicon Auto-Analyzer, Department
of Food Science and Human Nutrition, Michigan State Uni-
versity.

 

236

campus in the morning, prior to breakfast. These subjects
were instructed to collect the first urine voided upon
arising, and provided with a sterile swab, collection
device and suitable container. Twelve subjects were
admitted to the Health Center in the evening, and eight
women came on the morning of testing.

Twenty subjects submitted to the physical examination
(Appendix D-4) which emphasized clinical parameters
indicative of nutrient deficiency. In addition, each
woman was rated as appearing physically younger than,
older than, or typical of her age. To minimize variation
in judgment, all the subjects were examined by the same
physician. The clinical and biochemical data obtained were
examined in relation to nutrient intake, using correlation-
regression methods and analysis of variance. Clinical
parameters were examined in relation to nutrient intake
from food sources only, and therefore represent the minimum
intake of these individuals. Although six subjects reported
using a supplement which contained at least one of the
nutrients tabulated, it was not known how regularly such
Supplements were ingested. Furthermore, several of the
Supplements used were not realistic in respect to known
requirements, providing up to ten times the Recommended
Dietary Allowance (RDA) of the particular nutrient. One
Subject received, in addition, vitamin by injection from
her Physician, and the possibility exists that this was

true for others as well, who were given therapy regularly.

237

but were unaware of what was administered. When a clinical
abnormality was associated with lower mean nutrient intake,
this parameter was examined further in relation to intake
from known supplements. Biochemical parameters were studied
for all Clinical abnormalities observed.

It should be noted that 20 of the 28 women who
participated in the dietary survey, came to the Health
Center for examination. Two women aged, 68 and 81, resided
at some distance from Lansing, one living out of state, and
a third individual, aged 80, moved out of the state shortly
following the dietary interview. Two other subjects, aged
73 and 85, did not wish to be bothered. The younger of
these had diverticulitis, although she appeared to be
relatively active. The 85 year old drove from Lansing to
Chicago, a distance of 235 miles, once each month to visit
relatives, and considered herself to be too busy to parti—
cipate. The oldest subject, 90 years of age, had problems
with sight and hearing, and lived with a married daughter;
her main objection was distrust of physicians, rather than
physical disability. The desire to be left alone, was the
reason given by a woman aged 83, who still lived alone.
This subject seldom goes out, other than to accompany
neighbors who provide her with transportation to a food
market. Only one individual of the eight who did not
undergo the clinical examination, was prohibited from doing
so by physical disability. This woman, aged 75, had under—

gone surgery for intestinal cancer and was receiving cobalt

238

therapy. When approached again, the following year, she

was still confined to her home.

Results

Incidence of Clinical Abnormalities

 

When evaluated on the basis of general appearance,
a surprisingly large proportion (80%) of these older women
were in good condition. No individual was listed as in
poor condition, while four (20%) were rated as fair. A
rating of good or fair was not dependent upon the age of
the individual, as those rated fair were aged 69, 73, 75,

and 80 years.

Face and Skin.--The incidence of clinical abnor-

 

malities of the face and skin among the 20 subjects
examined are shown in Table V-3. Pallor was observed in
only one-fifth of those evaluated, however, the frequency
doubled with advancing age. Extreme paleness was not noted
in any subject below 70 years of age, although one-fourth
of those in the eighth decade, and one-half of those in the
ninth decade of life, showed this condition. Conversely,
the majority of the subjects in the younger age groups had
suborbital pigmentation. Mild hyperkeratosis of the

elbows and knees occurred in 12 and 13 subjects, respec-
tively, and was not more frequent in any particular age

group. One subject who was free of hyperkeratosis of the

239

Table V-3.--Incidence of Abnormalities of the Face and Skin
Among the Twenty Older Women Examined in 1972.a

 

With Abnormality

 

 

 

60-69 70-79 80-85
Characteristic Years Years Years
(8) (8) (4)
Face b
Pallor 0 25% (2) 50% (2)
Suborbital pigmentation 62% (5) 75% (6) 0
Nasolabial seborrhea 0 12% (l) 0
Skin
Xerosis 0 12% (l) 0
Hyperkeratosis (elbows) 62% (5) 62% (5) 50% (2)
Hyperkeratosis (knees) 62% (5) 62% (5) 75% (3)
Crackled skin 50% (4) 88% (7) 75% (3)
Creased skin 62% (5) 88% (7) 75% (3)
rPigmentation 12% (l) 12% (1) 25% (1)

 

aClinical evaluation performed by J. S. Feurig,
M.D., Olin Health Center, Michigan State University.

bActual numbers of subjects. ,

elbows, did show this lesion on the knees. Crackled and

creased skin were commonly observed in these subjects.

Eyes, Lips, Tongue, and Gums.--Lesions of the eyes,

 

lips, tongue, and gums, occurred among lesser percentages
of the women (Table V-4). Only two individuals showed
blepharitis, suggestive of serious vitamin A lack. One of
these had crusted eyelids as well, whereas both showed
abnormalities of the palpebral and bulbar conjunctivas.
The majority of the subjects had bulbar Spots, although

the etiology of this discoloration is not known.

240

Table V-4.--Incidence of Abnormalities of the Eyes, Lips,
Gums, and Tongue Among the Twenty Older Women
Examined in 1972.a

 

With Abnormality

 

 

 

60—69 70-79 80-85
Characteristic Years Years Years
(8)ID <8) (4)
Eyes b
Crusted eyelids 0 12% (l) 0
Blepharitis O 25% (2) 0
Bulbar spots 62% (5) 62% (5) 25% (l)
Lips
Angular stomatitis 38% (3) 25% (2) 0
Cheilosis 0 12% (l) 0
Gums
Gingivitis 0 12% (1) 0
Recession 62% (5) 50% (4) 75% (3)
Retraction 25% (2) 25% (2) 75% (3)
Tongue
Red (color) 12% (1) 25% (2) 0
Papillae,
Filliform, atrophy 38% (3) 38% (3) 25% (l)
Papillae,
Fungiform, atrOphy 25% (2) 12% (l) 0
Fissures 25% (2) 25% (2) 0

 

aClinical evaluations performed by J. S. Feurig,
M.D., Olin Health Center, Michigan State University.

bActual number of subjects.

241

Angular stomatitis, of a mild degree, was noted
among one-fourth of the subjects, whereas only one woman
had severe Cheilosis. Gum recession and retraction were
relatively common findings; one or both of these changes
had occurred in about half of the group, although the
frequency was highest among the oldest subjects. Dis-
colorations of the tongue were seldom seen, although
atrophy of the filliform papillae was observed in seven

wome n 0

Cardiovascular System.--Chronic cardiovascular

 

disorder, as judged by heart enlargement, was present in
one-third of the subjects (Table V-5); for two of them, the
hypertrophy was severe with accompanying mild general edema.
Fluid retention in the lower extremities was apparent in

9 of the 20 subjects; for three, the problem was serious.
Varicose veins were evident among half of these older

women, although this clinical problem was most frequent in
those 80 years of age or older. Irregularities in heart
rhythm, or the presence of a heart murmur, was not detected

in any of the women examined.

Skeletal System.--Aging has frequently been

 

associated with changes in the normal curvature of the
spine (Table V-6). Two such changes, kyphosis and
scoliosis, were not present in any of the women examined.

In contrast, six individuals were noted to have lordosis.

242

Table V—5.-—Incidence of Functional Abnormalities Relating
to the Cardiovascular System Among the Twenty
Older Women Examined in 1972.a

 

With Abnormality

 

 

 

60-69 70-79 80-85
Characteristic Years Years Years
(8)b (8) (4)
Cardiovascular system
Heart rhythm 0 0 0
Heart murmur
Functional 0 0 0
Organic 0 b 0 0
Abnormal size 25% (2) 50% (4) 25% (1)
General edema 12% (l) 12% (l) 0
Lower extremities
Edema 25% (2) 75% (6) 25% (l)
Varicose veins 50% (4) 38% (3) 75% (3)

 

aClinical evaluations performed by J. S. Feurig,
M.D., Olin Health Center, Michigan State University.

bActual number of subjects.

Neurological Reflexes.--Neurological abnormalities

 

(Table V-7) except for response to prOprioceptive stimuli
and Babinski reflex, were present in only one or two of the
women. One subject, aged 69, who suffers from myasthenia
gravis, a neuro-muscular disorder, had lost the normal
response to all reflexes tested. Nearly one-third of those
examined had diminished prOprioception while only two

women exhibited a normal Babinski reflex. Surprisingly,
both subjects retaining the normal Babinski response were

among the oldest examined, aged 81 and 85 years.

243

Table V-6.--Incidence of Abnormalities of the Spine Among
the Twenty Older Women Examined in 1972.a

 

With Abnormality

 

 

 

60-69 70-79 80—85
Characteristic Years Years Years
(8)]D (8) (4)
Spine
Kyphosis 0 b 0 0
Lordosis 50% (4) 25% (2) 0
Scoliosis 0 0 0

 

aclinical evaluations performed by J. S. Feurig,
M.D., Olin Health Center, Michigan State University.

bActual number of subjects.

Table V-7.--Incidence of Neurological Abnormalities Among
the Twenty Older Women Examined in 1972.a

 

With Abnormality

 

 

 

60-69 70-79 80-85
Characteristic Years Years Years
(8)b (8) (4)
Knee jerk 12% (1)b 0 0
Biceps jerk 12% (l) 0 0
Triceps jerk 12% (1) 0 0
Ankle jerk 12% (l) 0 0
Vibratory sense 12% (l) 12% (l) 0
PrOprioception 12% (l) 62% (5)
Babinski reflex 100% (8) 100% (8) 50% (2)

 

aClinical evaluations performed by J. S. Feurig,
M.D., Olin Health Center, Michigan State University.

bActual number of subjects.

244

Pulse Rate and Blood Pressure.--Individual values

 

for heart rate and systolic and diastolic blood pressure in
both 1948 and 1972 are shown in Table V—8. All subjects
examined in 1972, including those admitted to the Health
Center the morning of testing, had, following breakfast, at
least 30 minutes to rest in bed, before the clinical
evaluation. Pulse rates ranged from 72 to 78 beats per
minute for 19 of the older women, with one individual having
a rate of 82 beats per minute. Systolic hypertension (above
150 mm) was observed in eight subjects; the highest pressure
measured was 182 mm. That woman had expressed concern about
her husband who was in poor health, being alone at home.

Six individuals had diastolic pressures above 90 mm, and

for all of these, systolic pressures were also above

desirable levels.

Evaluation According to Age.--The physician, on the

 

basis of visual observation and physical examination of the
subjects, attempted to evaluate their condition relative to
what he considered normal for women of that age. One-fifth
(4) of the subjects appeared to be physically younger than
their age and moved about more easily than would be
expected. Two women were in poor physical condition
relative to their years. Three of the four subjects

judged to be in exceptionally good health were aged 80 or

above; those in poor health were 69 and 73 years of age.

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246

Dental Characteristics and
Food Restrictions

 

 

Although the majority of these women are dependent
upon partial or complete dentures to aid in the mastication
of food, they managed to enjoy a wide variety of items.

For only one individual, were food choices severely
restricted. As expected, a large proportion of these
women had lost many or all of their teeth; only three
subjects had lost three or less teeth. One of the latter
had been judged physically younger than her years, whereas
another was considered to appear older. Five of the women
had partial dentures and 12 had complete dentures. Of

this group, only one had been fitted with dentures (complete)
within one year of the survey. Four subjects having partial
dentures and 9.of the 12 edentulous subjects, had their
dentures for at least 20 years. Eight individuals had mild
to severe periodontal problems, although only two of these
reported any dietary restriction. As shown in Table V-9,
15 women have no limitations in food selection resulting
from mastication difficulties. One subject with partial
dentures avoided "tough" cuts of meat as did another who
was edentulous. Two women with complete dentures could

not incise firm fruits and vegetables such as raw apples

or celery stalks. Both individuals, however, included such
chOpped raw items in their diets. The woman most recently
fitted with complete dentures had to restrict her choice of

foods even further--she limited her meat to that which was

247

Table V-9.--Percent of Twenty Older Women Examined in 1972 Who
Restricted Their Food Intake Because of Dental Problems.

 

Food Restriction Few Teeth Lost Partial Dentures Complete Dentures

 

(3)* (5) (12)
None 100% (3)* 80% (4) 67% (8)
Foods that must 0 0 17% (2)
be incised
"Tough" meat 0 20% (l) 8% (1)
Ground meat only 0 O 8% (l)

 

*Number of subjects.

ground. For her, finances would not hinder any attempt to
remedy the problem.
Biochemical Indices of
NutritionaI Status

The nutritional status of these women, as evaluated
by laboratory tests, was assessed on the basis of standards
proposed by the International Committee on Nutrition for
National Defense (ICNND, 1963). Suggested guides to the
interpretation of blood and urine data are found in
Appendices D-5 and D-6. According to these standards, the
majority of the subjects examined received an adequate
nutrient intake. Serum or urine levels below those con-
sidered to be "acceptable" were noted for only three
nutritional parameters: total serum protein, serum
vitamin A, and urinary riboflavin excretion (Table V-lO

and V-ll).

248

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249

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250

Protein Status.--The serum protein levels (for

 

individual values, see Appendix D-7) for two-thirds of the
subjects were "acceptable" or "high" according to the
proposed standards (Table V-lO). Actually, eight of these
women had serum protein levels above 7.0 gm/100 ml.
Despite the fact that seven of the subjects had "low" or
"deficient" serum protein levels, the latter were not
associated with dietary practices. The two women with
"deficient" serum protein values (<6.0 gm/lOO ml) had daily
protein intakes of 46 and 73 grams. Surprisingly, for these
women, there was a significant negative relation (r=-0.566,
n=20, p=.01) between daily dietary protein expressed as
grams/kg body weight and total serum protein levels.

Although several individuals appeared deficient in
total serum protein, all subjects had acceptable or high
levels of serum albumin. As was true of total serum
protein levels, serum albumin level did not relate to daily
protein levels in either 1948 or 1972. The albumin value
was negatively related to protein calorie percent in 1972
(r=-0.483, n=20, p<.05). The reduced total serum protein
levels, noted in seven subjects, were the result of lowered
plasma globulin levels. This finding did not relate to any
dietary parameter.

Both total serum protein and serum albumin values
were examined in relation to the age of the subjects. Total
serum protein levels tended to increase with age, although

this was not statistically significant. Serum albumin ,

251

values, on the other hand, were unrelated to age. Serum

protein was not determined in the 1948 survey.

Iron Status.--Among these women iron nutriture

 

appeared adequate, as measures of hemoglobin and packed
cell volume were within normal ranges (for individual
values, see Appendix D-8). There was no relation between
the hemoglobin level and iron intake of these women in
either 1948 or 1972. Furthermore, the current RDA for iron
does not appear to be a reliable estimate of the needs of
this group. This is evident from the observation that the
subject with the lowest intake of dietary iron (6.2 mg per
day) which was less than two-thirds of that recommended
(Food and Nutrition Board, 1974) had a hemoglobin value of
14.7 gm/lOO ml. Neither hemoglobin level nor packed cell
volume was significantly associated with intakes of either
dietary iron or protein.

Blood smears for these women appeared normal with
no evidence of cells of abnormal size, as would be indi-
cative of either microcytic or macrocytic anemia. Megalo-
blastic anemia, the incidence of which usually increases
with age (Wintrobe et al., 1974, p. 604), was not present
in any of these subjects. The volumes of the red cells
were, in three women, slightly elevated (98 to 101 cubic
microns); for them, mean cell hemoglobin was increased
while red cell counts ranged from 4.0 to 4.5 million. Of

these three women, the one, aged 68, with the lowest red

252

blood cell count (4.05 million) had a mean daily iron intake
of 12.5 mg and consumed liver on one day of the survey; her
hemoglobin level was 13.0 g/100 ml. For this subject,
however, traces of occult blood were detected in the urine.
The other two individuals, aged 64 and 75 years, both had
adequate dietary iron, hemoglobin levels, and red cell
counts. Serum and percentage of transferrin bound iron,
was, for all subjects, in the normal range. In these
women, no parameter of iron status was found to be related
to age.

Hemoglobin levels as measured in 1972 were compared
with values obtained for these individuals in the 1948
survey. Hemoglobin levels in the former year ranged from
12.2 to 14.5 g/100 ml. Of the 12 subjects for whom
previous values were available, ten were observed to have
higher hemoglobin levels in 1972 than previously; this
increase ranged from 0.3 to 1.6 g/100 ml. The higher gains
were observed among women who, in 1948, were between the
ages of 40 and 52. One subject, aged 80, showed a decrease
in hemoglobin level from 14.0 to 13.3 g/100 ml, whereas for
another individual, aged 73, the same value (13.6 g/100 ml)

was recorded.

Vitamin Status

 

Vitamin A and Carotene.--Serum vitamin A and 8
carotene levels (for individual values, see Appendix D-9)

were acceptable to good for all but two subjects, one of

 

253

whom had less than 10 ug retinol/lOO ml and the other 18.
Both women had their gall bladders removed some years
earlier. DeSpite their low vitamin A blood levels their
dietary intakes were markedly different, with the first
woman consuming 1940 IU per day and the second supplementing
her dietary intake with 10,000 10 each day. Serum carotene
ranged from 64 to 372 ug/100 ml among all the subjects
examined. For the two individuals with low blood levels of
vitamin A (<10 and 18 ug/100 ml), 8 carotene levels were
within the normal range equalling 163 and 121 ug/100 ml,
respectively. Neither serum vitamin A nor carotene was
significantly related to dietary intake, calculated with
or without supplements. Furthermore, the level of vitamin A
in the serum was not related to the level of carotene. Age
was not associated with either parameter.

In 1948, serum vitamin A levels for these subjects
ranged from 0 to 67 ug/100 ml, and carotene levels from 37
to 149 ug/100 ml. There had been a marked drop in serum
vitamin A for the subject who in 1972 had only 18 ug
vitamin A/100 ml; in 1948 her recorded value was 67 ug.
Conversely, over this time, the carotene level in this
subject rose from 54 to 121 ug. No 1948 values were
available for the other subject exhibiting biochemical
evidence of vitamin A deficiency. Among the 10 women for
whom information in 1948 and 1972 permitted comparison,
seven showed increases in serum vitamin A, ranging from 1

to 58 ug. The woman for whom no serum vitamin A could be

254

detected in 1948, had in 1972, a value of 58 ug/100 ml.
Serum vitamin A dropped slightly in two of the subjects

examined. Carotene values rose in all individuals studied.

Ascorbic Acid.--The serum vitamin C levels were,

 

for all subjects but one, high, according to the ICNND
(1963) standards (for individual values, see Appendix D-9).
The lowest serum ascorbic acid level was 0.39 mg/100 ml;
the highest was 1.28 mg. In contrast to vitamin A, there
was a relation between serum ascorbic acid levels and
dietary intake including supplements (r=0.560, n=18,
p<.05). Serum ascorbic acid levels were not affected by
age.

Serum ascorbic levels tended to be higher when
measured in 1948 than in 1972. Six of the ten women
exhibited a decrease in serum ascorbate, the most pre-
cipitous drop being from 1.40 to 0.44 mg/100 ml. Some
determinations in 1948 may have been performed on non-
fasting blood samples. Four women were observed to have
higher serum levels of ascorbic acid in 1972; the individual
with the lowest ascorbic acid value in 1948, 0.30 mg/100 ml,
had a serum level of 0.95 mg in 1972. All blood analyzed

in 1972 was fasting.

Thiamin and Riboflavin.—-The urinary excretion

 

levels of thiamin and riboflavin calculated per gram of
creatinine (for individual values, see Appendices D-lO and

D-ll) are evaluated according to ICNND (1963) standards in

255

Table V-ll. The excretion levels of both vitamins were
significantly related to total dietary intake. Although
thiamin excretion was directly related to intake (r=0.528,
n=20, p<.05), the two lowest, although acceptable excretion
levels, were for individuals consuming 0.95 and 1.20 mg
thiamin daily. The urinary thiamin excretion data appeared
to confirm the suggestion that the requirement for this
vitamin is proportional to caloric intake. This was
evident from the fact that those women securing less than
two-thirds of the RDA for thiamin had relatively high
excretion values; however, their caloric intakes were low.

Urinary riboflavin, on the other hand, very closely
followed recorded intakes (r=0.767, n=20, p<.001). In
contrast to findings for thiamin, two of the three subjects
for whom riboflavin excretion was low according to accepted
standards (below 79 ug/gm of creatinine) had dietary
intakes approximating only two-thirds the RDA for this
vitamin. The third subject, with riboflavin excretion of
50 ug/gm creatinine, had a dietary intake of 1.29 mg.

When urinary vitamin levels were examined in regard
to age, it was found that thiamin excretion did increase
significantly with advancing age. This was not true of
urinary riboflavin. The finding regarding thiamin excretion
could relate to the fact that three of four subjects aged

80 or above, were receiving supplementary thiamin.

256

 

 

 

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257

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258

Relation Between Clinical
Symptoms, Nutrient Intake,
Physical Factors, and Age

 

 

 

Eyes, Lips, Tongue, and_Ggms.--The occurrence of

 

two lesions of the eye, crusted eyelids and blepharitis,
observed in one and two subjects, respectively, was sig-
nificantly related to vitamin A nutriture as indicated by
blood levels. These lesions were not associated with
dietary intake since one woman supplemented her daily diet
with 10,000 IU of the vitamin; the other secured less than
50 percent of the RDA. Both individuals had less than ade-
quate serum vitamin A values which equalled < 10 and 18
ug/100 ml. Age was not a factor associated with the
development of these lesions. Bulbar spots, on the other
hand, related to neither nutrient intake, biochemical param-
eters, nor age.

Dietary nutrients that are frequently associated
with lesions of the lips, tongue, and gums, are listed in
Table V-12. Angular stomatitis was diagnosed in five of
the 20 women examined. Contrary to what might be antici-
pated, dietary riboflavin was significantly higher for
those women in whom this lesion was observed. In addition,
these subjects had higher intakes of calcium and iron,
although the difference in dietary iron level was not sig-
nificant. For the women displaying angular stomatitis,
urinary riboflavin was, according to ICNND (1963) standards,

acceptable for three of the five and high for the remaining

259

two. Conversely, no individual with "low" riboflavin
excretion, indicative of inadequate dietary intake, had
oral lesions. In confirmation of the work of Machella and
McDonald (1943), four of the five subjects with fissures
at the corners of the mouth had either partial or complete
dentures. Age was not a factor in the development of
angular stomatitis.

Lesions of the tongue, as abnormal red color or
atrOphy of the filliform or fungiform papillae, were not
associated with low dietary intakes of iron, thiamin,
riboflavin, or niacin, nutrients frequently cited in
respect to the development of such lesions. Both thiamin
and riboflavin intakes were significantly higher in the
subjects exhibiting red tongue. Higher levels of the
latter vitamin were also associated with the incidence of
papillae atrophy, although niacin values did not differ
between those with and without papillae atrophy. Excretion
of the B vitamins was either acceptable or high for all
subjects observed to have red tongue or papillae atrophy,
with dietary intakes equalling at least 80 percent of the
RDA. One of the three individuals with a tongue of
abnormal color consumes, on doctor's prescription, a
dietary supplement containing the B complex. A second
individual in this group consumes at least one serving
daily of infant cereal, providing nearly 10 mg of iron

per serving, with high levels of thiamin, riboflavin and

260

niacin. Calcium intakes were higher in those women with
both red tongue and papillae atrophy; dietary riboflavin
levels in these individuals reflected generous servings of
milk.

Dentures, more than nutrient intake, may be
involved in some of the tongue abnormalities observed in
these women. This hypothesis is based on the fact that
three of the seven women with papillae atrophy were
ingesting dietary supplements providing the B vitamins and
iron, as compared with only 4 of the 13 subjects without
filliform atrophy. Although ascorbic acid intake from
food was significantly lower among the women with papillae
atrophy, calculations which included dietary supplements
revealed that only two individuals were consuming less
than 150 percent of the RDA for this vitamin. All three
women exhibiting red tongue, had papillae atrophy as well.
Age was unrelated to the occurrence of either tongue
abnormality. All women with red tongue wore dentures, as
did five of the seven with papillae atrophy.

In contrast, fissures of the tongue may be related
to dietary intake of ascorbic acid. Women with tongue
fissures ingested significantly less ascorbic acid than
those without fissures, a mean value of 42 mg as compared
with 110 mg. Two of the women with fissured tongues had
total intakes of ascorbic acid which equalled 27 and 36

mg, or 60 and 80 percent, respectively, of the RDA for

261

this vitamin. Serum ascorbic acid levels for these two
subjects were, however, 0.60 and 0.63 mg/100 ml, which was
not indicative of deficiency. The other two individuals
with fissured tongues ingested, with supplements, at least
100 mg of ascorbic acid daily; serum ascorbic acid levels
were for these women 0.83 and 0.95 mg/100 ml. Tongue
fissures were not associated with advancing age.

Receding and retracting gums were not related to
either dietary intake or age among these subjects. Despite
the fact that ascorbic acid nutriture is frequently associ-
ated with health of the gums, dietary levels of ascorbic
acid and serum ascorbic acid values were not related to
either gum recession or gum retraction. The lowest serum
ascorbate level observed was 0.39 mg/100 ml; that subject,

aged 69, had neither receding nor retracting gums.

General Appearance.--All subjects were rated by

 

the physician as to their general appearance, indicative
of their state of health. This rating was not always
related to their nutritional status as evidenced by either
dietary intake or biochemical tests. Sixteen women were
rated as good with four subjects rated as fair. As noted
in Table V-13, a rating of fair was associated with low
intakes of ascorbic acid and low relative body weights.
Mean dietary ascorbic acid equalled 111 mg for those whose
appearance was good as compared with an intake of 39 mg

for those rated as fair. When general appearance was

262

 

 

 

 

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263

good, the subjects tended to be somewhat overweight, mean
relative weight equalling 118.1, whereas those rated as
fair were underweight with a relative mean of 86.0. This
effect was not dependent on age, for the subjects rated
only fair in appearance were 69, 73, 75 and 80 years of
age. The biochemical data for these women revealed that
both subjects with serum vitamin A levels below 20 ug/100
ml were rated as fair. In contrast, the three subjects

with low urinary riboflavin excretion were rated as good.

Face and Skin.--Four women showed definite pallor,

 

and three of these had been rated as only fair in appear—
ance. Pallor, in these subjects, was associated with a
lower intake of dietary thiamin and advanced age (Table
V-14). Two of the subjects with extreme paleness had

only 52 and 79 percent of the RDA for thiamin, although
excretion levels of this vitamin were within an acceptable
range. On the other hand, three women with thiamin intakes
ranging from 61 to 78 percent of the RDA had normal skin
color. Iron intake did not differ generally between those
with and without pallor, although one subject who showed
this abnormality was consuming less than two-thirds of

the recommended level of iron. Hemoglobin levels were
normal for all subjects examined. One individual observed
to have pallor had a history of pernicious anemia, now
under control. The pale women were older, with two aged

80 or above, while the others were 73 and 75 years of age;

264

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265

 

 

 

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266

mean age differences were not statistically significant
(p < .07). Protein intakes were somewhat lower among
those with pallor.

In contrast to pallor which was noted in relatively
few subjects, other skin lesions as hyperkeratosis of the
elbows and knees, and crackled and creased skin, were
observed in the majority of individuals examined. Hyper-
keratosis of the elbows and/or knees (one subject showed
this symptom on the knees only) was significantly related
to lower intakes of linoleic acid. This value was 2.7
grams among those with hyperkeratosis of elbows and/or
knees as compared with 6.3 grams in the women with no such
symptoms. Levels of oleic acid and total fat were also
lower among those women whose skin was rough. This dif-
ference may lead to questions regarding the recommended
dietary level for linoleic acid. That suggestion is based
on the fact that eight of the thirteen women with lesions
had consumed the amount of linoleic acid recommended by
the Food and Nutrition Board (1974), two percent of total
calories. Age was not a factor in the appearance of hyper-
keratosis, nor was vitamin A status. Almost one-half of
the subjects with this problem had serum vitamin A levels
above 50 ug/lOO ml. The women with creased skin also
tended to have lower intakes of linoleic acid, although

this difference was not significant (p < .07).

 

 

In

267

Another skin abnormality, appearing less frequently
in these women, was extensive skin pigmentation, diagnosed
in three of twenty subjects examined. These three women
did have significantly higher intakes of dietary iron,
although biochemical parameters of iron status did not
differ between those with and without pigmented skin.
Extensive skin pigmentation would not seem to be related

to age, being observed in women aged 67, 75 and 81 years.

Skeletal System.--Deformity of the skeletal system

 

resulting in a loss in stature and/or a stooped appearance
in older people may be associated with overweight.
Although loss of calcium from the bone is frequently cited
(Garn, 1972) as a factor in vertebral changes, calcium
intakes for these subjects in neither 1948 nor 1972 were
associated with the development of lordosis, the only
spinal abnormality observed among these subjects (Table
V-lS). That overweight is a relevant factor in producing
spinal deformity in older people is suggested by the fact
that relative body weight in 1972 equalled 135.8 for the
six women with lordosis, whereas this value was only 98.4
among those with a normal spine, a significant difference.
Excessive weight over long periods of time may substan-
tially contribute to the development of this condition,

as the subjects exhibiting lordosis in 1972 were also
overweight when surveyed in 1948. Mean relative weight at

that time was 122.7 for those who now have lordosis,

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268

 

 

 

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269

compared with 102.9 for subjects with normal spines. Age
would not appear to be a controlling factor in regard to
this change, as none of the women in the oldest age group

had lordosis.

Neurological Reflexes.—-The loss of neurologic

 

function would appear to be associated with advancing age.
Eighteen of the twenty subjects examined had lost the
normal Babinski response, although both women retaining
this function were above the age of 80. These two subjects
were in excellent nutritional status in terms of nutrient
intake and biochemical measures, and had been evaluated
as being in better physical condition than is typical for
women of their age. Loss of proprioception was more
frequent among the women aged 70 to 79, than among those
aged 60-69. Women who had lost their response to pro-
prioceptive stimuli had higher intakes of saturated fat

and calcium.

Cardiovascular Function.--Two characteristics fre-

 

quently associated with cardiovascular dysfunction,
enlarged heart and edema of the lower extremities, in these
subjects, were not significantly related to nutrient
intake (Table V-16). Carbohydrate intake was higher among
subjects with normal heart size as compared to those with
cardiac hypertrophy, but this difference was not signifi-

cant (p = .06). No other differences in intakes of either

270

 

 

 

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271

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272

calories or macronutrients were observed between the two
groups. Dietary vitamin A was higher among the women
whose lower extremities were edematous, however, there was
no relation between serum vitamin A and fluid retention.
The principal factors associated with chronic
cardiac dysfunction in these women appeared to be hyper-
tension and relative body weight. The seven individuals
whose hearts were enlarged when evaluated in 1972, were
significantly above their ideal weights when examined in
both 1948 and 1972. In 1948 mean systolic blood pressure
did not differ significantly between those whose hearts
are now enlarged, and those with normal—sized hearts. Among
those with enlarged hearts, however, three of the five
subjects for whom 1948 blood pressure data is available
had systolic pressures above 150 mm. This also was true
for three of seven women with normal-sized hearts.
Similarly, diastolic blood pressure would appear to influ-
ence cardiac hypertrophy. Of the seven subjects with
normal-sized hearts for whom 1948 blood pressure data is
available, none had diastolic pressures above 90 mm; how-
ever, three of the five subjects whose hearts are now
enlarged in 1948 had diastolic pressures ranging from 95
to 132 mm. Consistent with this finding in 1948, systolic
and diastolic blood pressures as measured in 1972, were
hi9her among those with cardiac enlargement and edema, as

ComPared with individuals without these symptoms. Six of

273

seven subjects with enlarged hearts in 1972 had systolic
pressures above 150 mm, as compared with two of thirteen
in the other group. Similarly, four of the seven with
cardiac hypertrophy now exhibit diastolic hypertension;
this is true for only two of the others.

Varicose veins, another abnormality of the cardio-
vascular system, was observed in one-half of the subjects
examined. Although dietary intakes of iron were higher
among the women exhibiting this vascular problem, bio-
chemical parameters of iron status did not differ between
the two groups. Relative body weight as measured in
either 1948 or 1972 did not differ significantly between
those with and without varicose veins, although women with
varicose veins were above their ideal weight. The develop-
ment of this vascular lesion would appear to be signifi-
cantly influenced by blood pressure. Although systolic
and diastolic blood pressures, as measured in 1948, did
not differ between the two groups, systolic pressure in
1972, was significantly higher among those with this
lesion. Although the women with varicose veins tended to

be older, this difference was not significant.

Blood Pressure.--Regression relationships between

 

dietary intakes in 1948 and 1972, and blood pressure in
1972: were evaluated in these women. No significant rela-
tionships were found. Nutrient intake in 1948 was not

related to either systolic or diastolic blood pressure in

274

1972. Protein intake in 1972 was positively associated
with diastolic blood pressure, but this value did not
reach significance (p = .06). Similarly, systolic blood
pressure tended to rise with dietary intakes of total fat,
saturated fat, and oleic acid. Another parameter closely
associated with blood pressure is body weight. Relative
body weight in 1948 did seem to positively influence both
systolic and diastolic blood pressure as measured in 1972
(p = .07). The relative weights of the survey subjects
in 1972 were significantly related to both systolic
(r = 0.546, n = 20, p < .05) and diastolic (r = 0.478,
n = 20, p < .05) blood pressures.

Blood pressures tended to rise between 1948 and
1972 among those subjects for whom measures were avail-
able in both years. Comparison with the 1972 values
revealed that systolic blood pressure increased in seven
subjects, decreased in three, and remained relatively con-
stant (change < 10 mm) in two subjects. Two individuals
who in the recent study showed systolic hypertension
( > 150 mm), were normotensive in 1948. One individual,
aged 81, hypertensive in 1948, had in 1972, a systolic
pressure of 128 mm. Four individuals remained normotensive
and five subjects were hypertensive in both years. Simi-
larly, three women who, in 1948, had normal diastolic
pressures, now had diastolic pressures above 90 mm (one

Of these women developed systolic hypertension as well).

275

Six subjects have retained normal diastolic blood pressure
between 1948 and 1972, and two subjects remained hyper-
tensive. One individual showed a decrease in diastolic
pressure from 100 mm in 1948 to 88 mm in 1972.

Of the three women whose systolic blood pressure
dropped over the past 24 years, one is under treatment
for hypertension. For this individual systolic pressure
has dropped from 230 mm to 168 mm and diastolic pressure
from 132 to 102 mm. The other two subjects, aged 81 and
75, are being treated with diuretics; in addition, both
women lost about 25 pounds in body weight between 1948 and
1972. Changes in systolic blood pressure, however, do not
always reflect changes in body weight. For the two women
who develOped systolic hypertension over the 24-year
interval (systolic pressures increasing from 116 to 168 mm
and 140 to 182 mm), this change was not accompanied by an
increase in body weight; body weight changes represented
less than ten pounds. The latter individual, however, was
more than 40 percent above her ideal weight. Only two
among the eight women who in 1972 exhibited either systolic
and/or diastolic hypertension, are not being treated for
this disease. These individuals, aged 80 and 85, have
high systolic and diastolic pressures. That hypertension
may result in other abnormalities apart from the cardio-
vascular system is suggested by the observation that the

one subject whose urine contained both protein and occult

276

blood was hypertensive (Appendix D-lZ). This was also true
of a second individual whose test was positive for occult
blood. These subjects were 68 and 64 years of age,

respectively.

Physical Complaints.—-When the subjects were

 

questioned regarding the occurrence of repeating pains, ll
complained of such discomforts as arthritic pain in the
knees, back, or shoulder, or abdominal and chest pains.
However, the incidence of such pains was not related to
nutrient intake, body weight in either 1948 or 1972, or
age (Table V-l7). In contrast, women who tired easily had
significantly less riboflavin in their diets. Two of the
eight women who tired easily had excretion levels of ribo-
flavin indicative of low intake. Further examination of
parameters among those easily tiring revealed no differ-
ences in serum hemoglobin, relative body weight, or age,

as compared with those with greater work endurance.

Evaluation in Relation to Age.--Following the

 

physical examination, subjects were evaluated by the
clinician as physically appearing younger, older, or
typical of women of that age. This judgment was based
upon appearance (i.e., skin changes, tissue integrity)
and function (i.e., cardiovascular system, neurological
responses, locomotion). Because of the subjective nature

of this judgment, statistical tests were not applied to

 

 

 

 

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278

these results. Four subjects were considered to appear
younger, two subjects older, and 16 subjects typical of
their age.

The evaluation of daily nutrient intake of these
groups revealed that in 1948, the subjects appearing older
had low intakes of calcium, vitamin A and ascorbic acid.
Levels of calcium and vitamin A were approximately one-
third of that recommended. The lowered nutrient intakes
in 1948 of the subjects appearing older, may be explained
in part by the generally low food intake of these women.
Mean caloric intake was only 1104 kcal, compared with 1808
and 1838 kcal for the typical and younger-looking women,
respectively. The women appearing younger had, in 1948,
at least one—half the RDA for all nutrients except calcium.

In 1972, the women who appeared younger had gen-
erally good diets; the only nutrient to fall below 60
percent of the suggested recommendation was calcium. This
group had lower though adequate levels of protein and less
saturated fat and oleic acid, than those who appeared
typical or older. One of the subjects appearing "older"
had a very poor diet with less than half the RDA for
calcium, vitamin A, thiamin, and ascorbic acid. Although
this woman reported use of a dietary supplement providing
all vitamins and iron, her serum vitamin A level was less

than adequate.

279

Physical condition in later years may relate to
the degree of body fat. The two women appearing older
than their years were substantially underweight with a
mean relative value of 65.8. On the other hand, relative
weights among the four younger—appearing women were 100.6,
114.3, 122.8 and 143.8. Blood pressure per se did not
seem to influence the category into which these women were
classified. Among the four women who appeared younger, one
had both systolic and diastolic hypertension in 1972; she
was also slightly overweight (relative weight = 114.3).
Two others in this group had, in 1948, systolic pressures
above 150 mm. In contrast, the two subjects who appeared

older than their years had normal blood pressures in 1972.

Discussion

 

Problems in Assessing Nutritional
Status in Older PeOple

 

 

An attempt to relate the physical or health con-
dition of these older women to their prior or recent dietary
intake is fraught with difficulties. The latter include
all the problems associated with distinguishing observed
clinical abnormalities from the natural consequences of
aging. This difficulty is compounded by the differential
rates at which individuals age. Many older people have
memory lapses which interfere with attempts to pinpoint
the time when certain events related to their health and

Well-being occurred. Related thereto is the accuracy of

280

any dietary records that are obtained from older people.
Superimposed on these problems are the well-recognized
limitations of relating dietary intakes to nutritional
status. Although the signs and symptoms commonly seen in
individuals with classical deficiencies are well known, the
recognition of "sub-clinical syndromes" requires, for the
most part, differential diagnosis (Sinclair, 1948a;
Sandstead et al., 1969). Furthermore, the classical
clinical signs associated with nutritional abnormalities
among younger people may be pathognomonic of old age, or
secondary manifestations of diseases or traumas to which
old age is especially susceptible (Jolliffe and Most,
1943).

Despite these limitations, it appears desirable to
determine whether any relationships exist between an
individual's dietary practices at some previous time and
his current health status. The following discussion will
attempt to evaluate the results of the Lansing study in
the light of other reports and indicate the problems that
may be encountered, should this type of research be
repeated.

Clinical Aspects of Nutrition
and Aging

 

 

The skin is probably the most frequently used
criterion in estimating the age of an individual. With

age, the characteristics of the skin change from the

’1

281

"firm and elastic skin of a young person" to "the pale or
yellowed, somewhat flaccid and inelastic skin of the old
person" (Andrew, 1971, p. 71).

Skin abnormalities, as suborbital pigmentation,
hyperkeratosis of elbows and knees, and crackled and
creased epidermis, were each observed in over half of the
subjects. Suborbital pigmentation, although frequently
seen in malnourished individuals, has not been related
specifically to any one particular nutrient (Jolliffe and
Most, 1943; Sinclair, 1948). Although such pigmentation
has been associated with the eye lesions of vitamin A
deficiency, this was not true in the Lansing women; only
2 of the 11 with suborbital pigmentation had serum vitamin
A levels that were less than adequate. A more likely
cause of this change in skin color is age, as Andrew
(1971, p. 87) reported that brown, irregular areas of
pigment (lentigo senilis), seldom seen before the fourth
decade, tend to increase in size and number with advancing
years. This condition appears on the hands, forearms, and
face. No connection between the general condition of
health and these pigmented markings has been discerned.

A surprising observation was the presence of hyper~
keratosis among those women whose intake of linoleic acid
was, according to the Food and Nutrition Board (1974),
adequate. Additional work is needed to determine whether

the recommended level of linoleic acid should be increased

282

or possibly expressed as an absolute amount, rather than
as a percentage of total calories. This question is based
upon the observation that caloric intakes among these
women were approximately two-thirds of that suggested for
women above the age of 50 (1297 kcal versus 1800 kcal).
Although these subjects may have consumed two percent of
their calories as linoleic acid, intake may not have been
sufficient to meet body needs. One explanation for the
relatively low intakes of linoleic acid is the decrease in
total fat consumed by these subjects. A limitation of
dietary fat has been emphasized by the popular press as a
means of slowing degenerative vascular changes. Further—
more, high intakes of fat may cause abdominal distention
among older individuals.

The absolute amounts of dietary fat and linoleic
acid, in addition to the percent of fat as total calories,
were lower among those with dry skin than in those with
normal skin. As was true in this study, Plough and
Bridgforth (1960) found no correlation between dietary
vitamins and the appearance of follicular hyperkeratosis.
Those investigators did not examine linoleic acid intake.

Support for the concept that a deficient intake of
linoleic acid may be associated with hyperkeratosis comes
from the discussion of Deuel and Reiser (1955). They
reported that when subjects were fed a fat-free diet, the

primary tissue affected was the epidermis. Surface cells

283

were not shed normally, with subsequent thickening of this
layer. The lower transitional cell layers increased
markedly, and hyperkeratosis resulted.

On the other hand, other factors may contribute to
skin changes in older people. Creased and crackled skin
would appear to be non-specific lesions arising in old age
since these changes were not related to nutrient intake.
These skin changes may reflect the changes in the total
number of cells in the dermis as individuals age. Cell
concentration is highest during the first four decades of
life, and then declines (Andrew et al., 1964). A further
consequence of aging is the increase in fibrous material
with a concomitant decrease in the gel matrix. Sobel et
al. (1958) considered the relative proportion of skin
hexosamine to collagen to be an indicator of senescence
in both humans and animals.

Gillum and associates (1955a) reported an incidence
of mild to moderate skin xerosis in 28 percent of the 514
subjects over 50 years of age examined in San Mateo County,
California. As in the Lansing women, mean serum levels of
vitamin A were the same for those with and without skin
xerosis. The severity of the skin abnormality increased
with advancing age. In that study, xerosis was seen more
frequently in women. No data was reported relative to the
dietary fat intakes of those subjects. Similarly, Chieffi

and Kirk (1949) found, among 106 persons over 40 years of

284

age, that changes of the skin were influenced more by age
than by plasma vitamin A concentrations.

Lesions of the eyes, lips, tongue, and gums have
frequently been related to nutritional deficiencies among
subjects fed diets lacking in particular nutrients. How-
ever, when a random group of individuals is examined for
signs of nutritional disturbances, frequently only non-
specific findings are observed. An example of this diffi-
culty is seen in the report of a recent nutrition survey
(U.S. Department of Health, Education and Welfare, 1972).
From five to 10 percent of the women over 60 years of age
examined in that study had atrophy of the filliform or
fungiform papillae, whereas eight percent exhibited tongue
fissures. Although the general findings of the survey
suggested that nutritional problems occurred more fre-
quently among lower-income than higher-income subjects,
the tongue lesions were more frequent in the states with
the higher incomes.

Further evidence that tongue and oral abnormalities
are not always of nutritional origin comes from the work
of Plough and Bridgforth (1960). They detected no corre-
lation between angular lesions, cheilosis, papillae
atrophy, or tongue discoloration, and dietary riboflavin,
niacin, or iron. Cheilosis may result from climatic
eXposure or local trauma or irritation, and angular lesions

frequently reflect ill-fitting dentures. According to

285

Horwitt and coworkers (1950), oral lesions appeared in
riboflavin-deprived subjects when urinary excretion fell
below 40 ug per day. That the latter is not an infallible
finding is suggested by the observation that the three
individuals in the Lansing study for whom urinary ribo-
flavin excretions were 37, 49, and 50 ug per gram of
creatinine, showed no oral abnormalities. Alternatively,
four of the five women with angular lesions used dentures.
This was also true for five of the seven subjects with
filliform atrophy of the tongue. Evidence to support the
conclusion that denudation of the filliform papillae may
result from dentures comes from the work of Sinclair
(1948). Among 3184 Dutch subjects, including all ages and
both sexes, a smooth tongue was nearly three times as
frequent in those having dentures as compared with those
who did not.

According to Sinclair (1948a), a scarlet or
magenta tongue is non-specific in origin since foods high
in temperature or spices may produce bright red fungiform
papillae. Confirmation that these tongue lesions may not
be related to nutrient intake comes from the observation
that one of the three individuals with a red tongue was
ingesting, on a doctor's prescription, a high potency B
Vitamin supplement. Tongue fissures may also be deceptive

as they can occur congenitally, appearing in about five

286

percent of the population. The frequency of this condition
increases with age (Gorlin and Boyle, 1966).

The results of the Lansing study suggest that
dietary intakes of thiamin, niacin, riboflavin, and iron
were not related to the appearance of oral lesions. That
was based on both nutrient intake data and biochemical
indices of nutritional status; however, the possible role
of pyridoxine, folic acid, vitamin B12, or zinc in the
develOpment of these lesions, cannot be ignored. The
occurrence of oral lesions among older people should not
be used to propose that older individuals have an increased
requirement for various B complex vitamins and iron. This
is supported by the fact that equal numbers of the
Lansing women, with and without these symptoms, were
ingesting between 66 and 100 percent of the RDA for these
nutrients, with no additional supplements.

The loss of classical neurological responses as
knee jerk and Babinski reflex has been related to defici-
encies of thiamin and vitamin B12. In the Lansing study
the loss of knee and ankle responses in one individual
reflected disease rather than nutritional state. That
subject had myasthenia gravis, with resultant loss of
muscle tone. Other investigators have reported the
existence of clinical neurological abnormalities among
older individuals. Carter (1971) surveying 100 individuals

over the age of 70, observed abnormal neurological

287

responses in 80 percent of those examined. These neuro-
logical changes were attributed to a loss of neurons,
associated with advanced age. Although the six women
exhibiting abnormal proprioception had high levels of
dietary saturated fat and calcium, the significance of
such relationships are not understood. Andrew (1971,
p. 227) reported that one of the more conspicuous degenera-
tive changes occurring in the nerve cell as a consequence
of aging, is the accumulation of fat. Whether the rate at
which fat is deposited is more rapid in those individuals
whose diets are rich in this nutrient, is not known.
Cardiovascular Function and
Blood Pressure in Older Women

A positive association between obesity and blood
pressure in young and middle-aged adults has been described
in a compilation of life insurance data (Society of
Actuaries, 1959). That this relationship is also true in
individuals of advanced age is suggested by the results
of the Lansing study. Of the eight women exhibiting
either systolic and/or diastolic hypertension, all but one
were obese. Similar findings were reported by Chope and
Dray (1951), who examined 577 older subjects in San Mateo
County, California. In that study 32 percent of those
examined were hypertensive, and 27 percent of these were

obese. Another worker (Goodman, 1955) found that 75

288

percent of his older, obese subjects had systolic and/or
diastolic blood pressures over 150 mm and 90 mm, respec~
tively.

This demonstrated relationship between obesity and
high blood pressure among human subjects is frequently
used as an argument to encourage weight reduction among
older individuals. Evidence from several sources indi-
cates, however, that overweight does not always predispose
the individual to hypertension. In a study of 50 extremely
obese subjects (Alexander et al., 1962), systolic and
diastolic blood pressures of 150 mm and 90 mm or higher,
were recorded in one-half of the patients tested, and
pressures greater than 200 mm and 120 mm were observed in
10 percent of the group. On the other hand, two-fifths of
the remaining individuals were normotensive. Those
authors concluded that obesity, even when extreme, will
not always result in the development of hypertension.
Similarly, among the Lansing subjects, two women who were
20 to 40 percent overweight, had blood pressures of 128/82
and 138/86, respectively.

Elevated blood pressure may be a characteristic
of advancing age. Some reports (Lasser and Master, 1959)
suggest a steady rise in average systolic and diastolic

blc>od pressures up to the age of 70, with diastolic pres-
sures remaining stable beyond that age. Others (Engel and

Malmstrom, 1967) have observed that blood pressures may

289

rise at a relatively moderate rate into advanced age,
followed by a later, rapid rise. In contrast to these
reports, a sharp rise in blood pressure over the past 24
years was noted in only two Lansing subjects who had normal
systolic pressures in 1948 but later exhibited systolic
hypertension. Contrary to what might have been antici-
pated, blood pressure dropped in four of the 12 individuals
for whom measurements were available in both years. This
could be the result of the increased availability of
pharmacologic agents for controlling blood pressure.
Another possible explanation for this decline in blood
pressure comes from the work of Brown and coworkers (1963).
In that study of 100 subjects over 61 years of age, a
decline in blood pressure from hypertensive to normo-
tensive levels was frequently associated with the onset or
exacerbation of congestive heart failure.

Ventricular hypertrophy may be indicative of
serious underlying disease. Hurst and Logue (1970) con-
sider cardiac enlargement to be reliable evidence of heart
disease. Furthermore, an enlarged heart is more likely to
be associated with heart failure than is a heart of normal
size. One clinical syndrome associated with heart failure
is edema in the feet, ankles, and lower leg. All but one
of the Lansing women with enlarged hearts had edema of the
lower extremities. Two other women experiencing fluid

retention were overweight or hypertensive. It must be

290

recognized that other factors, completely unrelated to
heart disease may contribute to edema; varicose veins,
obesity, renal disturbances, phlebitis, steroid adminis-
tration, or prolonged periods of standing or sitting, may
result in this clinical abnormality (Hurst and Logue, 1970).
Seven of the Lansing women were observed to have
cardiac hypertrophy. An enlarged heart may be the result
of prolonged elevated blood pressure. That body weight
may also be a factor in the development of cardiac hyper-
trophy is suggested by epidemiological evidence. Among
the women in Tecumseh, Michigan (Epstein et al., 1965),
hypertensive heart disease, as denoted by both elevated
blood pressure and ventricular hypertrophy, was significantly
associated with relative weight. In the Lansing study, five
of the seven women whose hearts were enlarged were both
hypertensive and/or overweight. Only one of the subjects
who, in 1972, was observed to have cardiac hypertrophy was
not either hypertensive or at least 10 percent overweight
in 1948. The means by which excessive body weight and
elevated blood pressure, in addition to other factors still
unknown, may over periods of time be involved in the
development of cardiac enlargement, remain to be

elucidated.

 

291

Dental Status and Nutrient
Intake

The dental status of the Lansing women was not
related to their nutritional status. Gum lesions associ-
ated with gingivitis were seen in only one subject; her
serum ascorbic acid level was above 1.0 mg/100 ml. Simi-
larly, Morgan and associates (1955) noted that 12 percent
of their aged subjects had gingivitis. Other investigators
(Andrews et al., 1969) have reported that sublingual
lesions in elderly patients which failed to respond to
supplementation with 40-80 mg of ascorbic acid daily,
proved, upon histological examination, to be aneurysmal
dilations of the venules with no evidence of hemorrhage or
localized inflammation.

In like manner, gum recession and retraction were
not related to either nutrient intake or age. According
to Gorlin and Boyle (1966) that condition is symptomatic
of advanced periodontal disease. Marginal periodontal
disease is more common in older individuals, among whom it
is the primary cause of tooth loss. Patients with a
chronic disease, as diabetes mellitus, are especially sus-
ceptible to this condition. Nutritional deficiencies can
accelerate the loss of dental supporting structures.
Other inNestigators (Ship and Burket, 1965) have reported
a generalized mucosal atrophy occurring at the menOpause,

Vwith pronounced changes in the metabolism and appearance

of oral tissues.

292

Concern is frequently expressed about the influence
of dental status of older subjects upon their food choices
and consequent nutrient intake. One of the Lansing women
claimed she was restricted for dental reasons to ground
meat, while two others avoided "tough" meat. All three of
these had more than 100 percent of the recommended level
of protein. That dentures do not necessarily restrict
meat choices is suggested by the observation that both
individuals who consumed steak during the dietary survey
had complete dentures. Further evidence that loss of
teeth does not predispose one to a low nitrogen intake comes
from the work of Neill and Phillips (1970). They evaluated
masticatory performance and dietary intake in 53 elderly
males who had partial or complete dentures, or who were
edentulous with no dentures; no differences existed among
those with a good, fair, or poor dental state. Although
the men with good dentition consumed the most calories,
intake of animal protein varied from 63 grams in those with
a good dental state to 58 grams in those with a fair or
poor dental state. In another study of apparently healthy
aged people (Davidson et al., 1962) protein intake, cal-
culated as grams/kg body weight, was inversely correlated
with chewing efficiency.

Another dietary problem associated with dentition,
is the consumption of fruits and vegetables. Several sub-

jects in the Lansing study admitted avoiding some fruits

293

and vegetables; however, this may be more apparent than
real. One woman claimed she restricted her intake of hard
foods which required pressure to bite. Despite this, she
recorded eating a salad containing raw chOpped apple.
Evidence that state of dentition may influence ascorbic
acid status comes from the study of the San Mateo elderly
(Morgan et al., 1955). One-half of the subjects with serum
ascorbic acid levels below 0.5 mg/100 ml were edentulous,
whereas, complete loss of teeth was noted among only one-
third of those with serum levels above 1.1 mg/100 ml. In
that the most consistent source of ascorbic acid among the
Lansing women was frozen orange juice, the state of

dentition should not influence the intake of this nutrient.

Biochemical Measures of Nutritional
Status in Older Women

Biochemical parameters have been used frequently
to evaluate nutritional status in individuals of all ages.
For many nutrients, however, the relationships between
nutrient intake and blood or urine parameters are not well
understood. In older individuals in whom normal homeo-
static mechanisms may be impaired, biochemical measure-
ments are even less reliable indicators of nutriture.
Nevertheless, in that other methods of evaluation are not
available, biochemical parameters in the Lansing women were

evaluated in terms of nutrient intake and clinical findings.

294

The level of serum protein is frequently used to
identify those individuals whose protein intake is inade-
quate. That this may not be a valid procedure to apply to
older people is suggested by the results of this study.
Seven of the 20 women examined had serum protein levels
which, by ICNND (1963) standards, were less than adequate.
However, all seven of these women listed protein intakes
which equalled or exceeded the RDA. Although the reported
caloric intakes of these women were very low, there was
no indication that any of them were losing weight. This
observation would suggest that dietary caloric deficiency
was not responsible for the implied protein deficiency.
Roberts and coworkers (1948) did report, however, that
older women consuming less than 1800 kcalories daily were
unable to remain in positive nitrogen balance, regardless
of the level of protein fed. That further work is required
to resolve this question is suggested by the fact that six
of the seven subjects with low serum protein levels were
«:onsuming 1439 kcalories or less each day. The remaining
saubject whose total serum protein equalled only 6.1 grams/
1130 ml, was consuming 1815 kcalories each day and 81 grams
protein.

The majority of the Lansing women, however, had
serum protein levels which were within the normal ranges

established for healthy young individuals. This finding

i}; at variance with those reports which suggest that serum

295

protein concentration, particularly serum albumin concen—
tration, decreases with advancing years. One such study

of 194 healthy males between 20 and 89 years of age indi-
cated that serum albumin levels decreased with age, despite
adequate dietary protein (Leto et al., 1970). Similarly,
Reed and coworkers (1972) reported that the upper limits of
albumin concentration determined in 1137 individuals by

SMA 12/60 automated screening procedures, declined after
the age of 40, with the effect being more pronounced in
males.

Serum albumin levels were normal in those individ-
uals with low total serum protein, suggesting that in these
women, the globulin fraction decreased. This is in con-
trast to the findings of Woodford—Williams et al. (1965)
who reported that in their older subjects, the albumin
concentration declined while the globulin fractions rose.
Other workers (Reed et al., 1972) also have noted that the
albumin/globulin ratio decreased with age, accompanied by
a slight decline in total serum protein.

The aged is one group believed vulnerable to
nutritional iron deficiency. This has been stressed by a
number of investigators who have reported reductions in
hemoglobin, hematocrit, and erythrocyte levels, among
healthy older people. Shapleigh and coworkers (1952) came
to that conclusion on the basis of a study of 100 healthy

individuals over 60 years of age. They observed that the

296

reduction in hematologic characteristics was more pro—
nounced among males, resulting in a narrowing of the
normal difference between men and women. Changes in the
total number or types of white cells were non-consistent.
Similar findings among 140 healthy aged were reported by
Renbourn and Ellison (1952), although they concluded that
there was no evidence of anemia among their subjects.

The infrequency of iron-deficiency anemia among older
people was implied by the results of a recent nutritional
survey (U.S. Dept. of Health, Education and Welfare, 1972a).
Less than five percent of the subjects over 60 years of
age had iron-deficiency anemia.

There was no iron-deficiency anemia among the

Lansing women, although for several, the mean cell volume
(MCV) was slightly above accepted standards. For these
three subjects MCV ranged from 98 to 101 cubic microns.
Whether this suggests a fundamental change in the
erythrocyte in advanced age, or the first indication of
a develoPing megaloblastic anemia, is open to question.
In no case did the blood smear indicate the existence of
megaloblastic cells. Wintrobe et al. (1974, p. 568),
considers an MCV of 95 cubic microns the upper limit of
normal, while another hemotalogist (Miale, 1972, p. 644)
suggests that an MCV above 100 or 105 cubic microns is
indicative of megaloblastosis. In light of the inherent

errors of the hematocrit and erythrocyte count, that author

297

concludes that borderline values should be interpreted with
caution. Among the women with high MCVs, mean corpuscular
hemoglobin concentration remained at normal levels,
suggesting that cellular hemoglobin content increased.

It should be noted that one subject who has periodically
been treated for pernicious anemia, showed no evidence of
megaloblastosis. Blood levels of folic acid and vitamin
B12 were not determined.

That the MCV may increase in old age is suggested
by the results of a number of investigators. One such
study among 100 elderly males and females indicated a mean
corpuscular volume of 97.7 cubic microns (Newman and Gitlow,
1943). Furthermore, other workers (Spriggs and Sladden,
1958) noted that red cell diameters, measured in persons
aged one to 90, increased significantly in each decade after
the age of 40. Spriggs and Sladden (1958) therefore con-
cluded that the erythrocytes of aged persons with no evi-
dence of megaloblastic anemia, often show moderate degrees
of enlargement. In the young, such findings would be
considered indicative of a serious disease. It would seem
appropriate that aged individuals with borderline values
be monitored on a frequent basis to see if their MCV values
remain stationary, as might be indicative of normal aging.
.If blood indices continue to move rapidly away from
aczcepted standards, diagnosis to determine the nature of

‘the megaloblastosis should be instituted.

298

Vitamin A nutriture is usually assessed on the
basis of blood levels, and from the resulting values,
conclusions are made about the vitamin intake. That this
may not be a valid procedure to use among older people
whose nutritional state may be altered by the effects of
chronic disease, is suggested by the results of the Lansing
study. No significant relationship existed between vitamin
A intake, with or without the inclusion of supplements,
and serum levels. In like manner, Plough and Bridgforth
(1960), analyzing data obtained from eight countries, con-
cluded that dietary vitamin levels did not correlate with
either serum vitamin A or carotene.

Two Lansing subjects had serum levels of vitamin A
which were below the acceptable range; this, despite
reasonable intakes of the vitamin. In these cases the low
blood levels may be related to diminished fat absorption,
compounded by the regular use of laxatives. Both of these
subjects had undergone cholecystectomies in recent years,
rzesulting in a decreased ability to handle dietary fat.
The subject with the serum A level of 18 ug/100 ml ingested
a: supplement providing 10,000 IU of the vitamin daily.
jaer-urinary excretion levels of the B complex factors con-
;firmed her use of a vitamin supplement, but her extremely
low'body weight (relative weight = 65.4) suggests that she

may have had difficulty in assimilating adequate calories;

her energy intake was 1173 kcalories.

299

The other subject with a low serum vitamin A level
(< 10 ug/100 ml) had a borderline vitamin A intake to begin
with (1940 IU), avoided fat in her diet, and as a conse-
quence of colonic diverticulosis, used a cathartic regu-
larly. In addition, she frequently relied upon an anal-
gesic (Darvon) to relieve abdominal distress following
meals. One fact which cannot be overlooked, however, is
the relatively high serum carotene level in this subject
(163 ug/100 ml). For all subjects, the calculated intakes
of vitamin A included both the preformed vitamin plus B
carotene. This subject secured about one-half of her
vitamin A intake from fortified skim milk, with the other
coming from vegetables and canned fruit. She followed a
rather circumspect diet, prescribed by her physician for
the treatment of diverticulosis; consequently, she is
severely limited in her choice of vegetables, but did
include carrots when enumerating those which she does con-
sume. Carrots, however, were not included on any of the
dietary record days. The relatively high level of B
carotene in her serum and the very low vitamin A level
suggest that any carotene ingested is not being converted
to vitamin A. There is also the possibility that the serum
c=arotene includes non-biologically active pigments. Since
iJisurance statistics (Metropolitan Life Insurance Company,
1972) suggest that over 15 million persons in this country

suffer from gall bladder disease, additional work should

 

 

300

be done among such older subjects to determine whether
there is any abnormality in the metabolism of the fat-
:—mlublc vitamins.

Reduced intestinal absorption of the fat-soluble
vitamins has been attributed most frequently to a reduction
in bile (associated with a cholecystectomy) or the routine
use of mineral oil as a cathartic. Increasing evidence
suggests there may be other factors, especially among
older people, that influence the absorption of these
nutrients. This appears to be so, for even when mineral
oil is used regularly, the serum levels of the fat-soluble
vitamins are not always predictable. This was evident in
the report by Gillum and associates (1955a). Two of their
subjects who ingested mineral oil every day had the same
serum levels of vitamin A (33 and 34 ug/lOO ml) but a two-
fold difference in carotene levels (122 and 224 ug/100 m1).
This finding existed despite high intakes of vitamin A
(8290 and 9791 IU as the sum of both preformed retinol and
g carotene). Another subject studied by Gillum et al.
(1955a), with no apparent gall bladder disease nor known
'use of mineral oil, had relatively low serum vitamin levels
«despite very high intakes of both vitamin A and carotene.
Ilis serum levels were 54 ug/lOO ml of vitamin A and 69
“ug/lOO ml of carotene while his intakes (including supple-

Iments) were 69,350 and 17,288 IU, respectively.

301

Age is another factor that has been considered to
affect serum vitamin levels in that the aging process may
result in a decreased absorptive capacity. That this may
not be a valid assumption is suggested by the Lansing
results, for serum levels of vitamin A were adequate to
high in 18 of the 20 women examined. Furthermore, a recent
survey of both males and females in the United States
(U.S. Dept. of Health, Education and Welfare, 1972a) indi-
cated that mean serum vitamin A levels actually increased
with the age of the subjects; less than two percent of the
individuals over the age of 59 were classed as deficient.
Further evidence to suggest that age, per se, may not
reduce the absorption and storage of vitamin A comes from
the work of Underwood et al. (1970). They found that liver
stores of vitamin A in subjects dying from unnatural
causes equalled 126, 96, and 147 ug/g, among those aged
10-19, 20-49, and 50 years of age or above, respectively.

Food choices of the Lansing women had some influence
upon their serum vitamin A levels. This was especially
.apparent among those women whose serum retinol levels were
above 60 ug/100 ml. Those women ingested liver, used a
liigh potency supplement, or in one instance consumed
spinach several times weekly. The seasonal factor was
emphasized in the report of a study of the people in
Onondago County, New York (Dibble et al., 1967) . Among

those subjects the calculated vitamin A intakes were

302

higher in the fall than in the spring, reflecting the
increased availability of fresh fruits and green and yellow
vegetables. This might also explain the high serum varn—
tene levels among the Lansing subjects since their dietary
records were made in the summer and early autumn.

In contrast to serum vitamin A and carotene which
were not related to dietary intake, serum ascorbic acid
was significantly dependent upon the amount ingested. On
the basis of serum vitamin C levels, none of the Lansing
subjects were deficient. The differential serum ascorbic
acid levels in males and females initially recognized in
younger people (Brown et al., 1943) is maintained into old
age. That conclusion is based on the report of Morgan
and associates (1955) who observed that older women had
higher serum vitamin C levels than men, despite lower
intakes. In that study, eight percent of the women had
serum ascorbic acid levels below 0.3 mg/100 ml, whereas
this was not true for any of the Lansing subjects. The
latter finding is in agreement with the results of a
recent national survey (U.S. Dept. of Health, Education
and Welfare, 1972a). According to that report, ascorbic
acid status was not a problem among older women.

Some controversy exists regarding the requirements

<3f'older people for the B complex vitamins. Results of
time Lansing study indicate that both thiamin and riboflavin

«excretions were related to total dietary intake. The

 

303

thiamin requirement is frequently expressed in terms of the
caloric intake of the individual. Two of the Lansingsub-
jects were consuming only about one-half to two-thirds
(0.52 and 0.61 mg) of the RDA for thiamin, but intake was
still adequate in that it provided 0.5 mg/1000 calories.
Furthermore, urinary thiamin excretion was adequate as
based upon the creatinine content of the same sample.
Oldham and coworkers (1946), studying thiamin metabolism
in healthy women, concluded that an intake of 0.5 mg/1000
calories was probably sufficient to maintain tissue con-
centrations.

Other investigators have studied thiamin require-
ments by the measurement of thiamin excretion at various
levels of intake. Mickelsen and coworkers (1947) found
among their young male subjects that thiamin excretion
equalled only 5 ug daily on intakes of 0.61 mg of vitamin
daily, but rose to 224 ug on a thiamin intake of 2.00 mg.
Excretion levels among the older Lansing women were con-
siderably higher on these levels of intake. Several
factors may contribute to this difference. The caloric
intake of the Lansing women was relatively low; 9 of the
20 subjects were consuming about 1200 or less kcalories
(each day. Although the caloric intakes of the young men
cusserved by Mickelsen et al. (1947) were not given, these
were most likely higher values. Secondly, the excretions

(3f the young men were determined on 24-hour urine

 

 

304

collections, as compared with an overnight fasting sample
obtained from the older women. Another factor is the
variation among individuals. Mickelsen et al. (1947)
pointed out that one "normal" person may excrete twice
or even three times as much thiamin as another "normal"
person on the same vitamin intake. This characteristic
observed in young subjects, also existed among the older
individuals aged 63 to 89 years, studied by Rafsky and
Newman (1943).

Thiamin excretion levels tended to be high among
the Lansing subjects who increased their dietary intakes
by the use of supplements or highly fortified cereal pro-
ducts. The individual with the highest urinary thiamin
level (3726 ug/gm creatinine) was ingesting daily a multi-
vitamin supplement containing 2.5 mg thiamin, and, in
addition, was given a B complex supplement by her physician.
Other investigators have confirmed the adequacy of thiamin
nutriture among most older people. In a recent Ten—State
Nutrition Survey (U.S. Dept. Health, Education and Welfare,
1972a), less than 3 percent of the subjects above the age
of 59 had excretion values below 70 ug/gm creatinine,
levels indicative of deficient or low intakes. Alter—
natively, 58 percent of the subjects had excretion levels
loetween 120 and 500 ug/gm creatinine. This proportion
<:ompares favorably with the Lansing study in which 11 of

'the 20 women had urinary thiamin ratios equalling ll9

305

to 495 ug/gm creatinine. In the Ten-State Survey, one-
fourth of the older subjects excreted more than 499 ug
thiamin/gm creatinine daily.

Although all of the Lansing subjects reflected
adequate intakes of thiamin, this was not true for ribo-
flavin. Three subjects had low levels of riboflavin
excretion, which in two cases could be attributed to
dietary intakes less than or equal to only two-thirds of
the RDA. The third subject, excreting 50 ug of riboflavin/
gm creatinine, had a mean daily intake of 1.29 mg ribo—
flavin, actually exceeding the RDA. For the most part,
urinary riboflavin levels were high, reflecting the con-
sumption of liver and the use of dietary supplements by
these women. On a national basis (U.S. Dept. of Health,
Education and Welfare, 1972a) the incidence of deficient
or low excretory levels of riboflavin among older people,
was twice that of thiamin.

The dietary intakes and excretion levels of the B
complex vitamins observed in the Lansing women provide no
evidence that normal older individuals require higher
levels of these nutrients than young adults. Alternatively,
these older women excreted higher levels of thiamin on
specific intakes than did the young men studied by
Mickelsen et al. (1947). These data are not strictly
comparable in that only one fasting urine sample was

czollected from the older women compared to the numerous

306

24-hour collections followed in the metabolic study. The
lowest thiamin excretion noted in the older women, 119 ug/
gm creatinine, despite intakes among some subjects which
were two—thirds or less of the RDA, was considerably above
that of young men ingesting 1.0 mg of thiamin daily--the
latter was 65 ug. One argument advanced in justification
of higher than normal intakes of vitamins by older individ-
uals is possible aberrations in intermediary metabolism.
Whether such problems exist within specific individuals is
not known. Shock has, however, described the
reduction in kidney function which occurs as a consequence
of normal aging. For this reason, the practice of indis-
criminate ingestion of high potency supplements which
could result in additional stress upon a less efficient
kidney, should be seriously questioned.

The judgment about the thiamin and riboflavin
nutriture of the Michigan women may be faulty since only
one urine sample was collected. There is a possibility
that the day-to-day variation in urinary vitamin excretion
might be such that the samples secured did not accurately
reflect dietary intake. That such variability may exist
has been suggested by Hegsted and coworkers (1956) who
found considerable variation in riboflavin excretion from
day to day in the same subjects. A further concern
regarding the urine samples obtained from the Lansing

women is the time period of collection. These samples did

307

not represent a 24—hour excretion; they were overnight
samples from which the vitamin excretion levels were, on
the basis of creatinine content, translated into 24-hour
values. The latter concept has been questioned by Vester-
gaard and Leverett (1958) who observed considerable vari-
ation in creatinine excretion among their subjects through-
out the 24-hour period. Despite the absence of 24-hour
urine collections, it is doubtful whether the conclusions
about the thiamin and riboflavin nutriture of these women

would be altered by complete urine samples.

Conclusions

 

Clinical symptoms often associated with nutritional
deficiencies, in older women, are not always related to
inadequate nutrient intake. Oral lesions as angular
stomatitis and atrophy of the filliform and fungiform
papillae, appeared to be the result of dentures rather
than a deficiency of the B complex vitamins or iron.
Hyperkeratosis of the elbows and knees may be caused by a
lack of linoleic acid. Pathologic changes in neurologic
responses as well as the creasing of the skin seem to be a
natural accompaniment of advancing age, unaffected by
nutritional status.

Hypertension and overweight acting over a period
of the lifespan may influence the development of cardiac
hypertrophy. Blood pressure, in women, seems to remain

stationary or even decrease from middle to advanced age.

308

Dental status among older women does not signifi-
cantly influence nutrient intake; similar foods are con-
sumed by those with natural teeth or dentures.

Biochemical values observed in older women generally
parallel those seen in younger individuals. Serum vitamin
A and carotene cannot be correlated with dietary intake in
older individuals, and may be deficient or low as a result
of chronic disease (i.e., diverticulosis or gall bladder
insufficiency). Ascorbic acid, thiamin, riboflavin and
iron nutriture, would seem to be adequate in most older
women. Decreased levels of serum protein reflect changes
in the globulin fraction; albumin levels are within normal
ranges despite the low globulin levels. Advancing age may
result in a gradual increase in red cell volume in sub-

jects with no overt signs of megaloblastic anemia.

CHAPTER VI

PHYSICAL MEASUREMENTS AND GLUCOSE

TOLERANCE IN OLDER WOMEN

Introduction

 

Correlations have been established between the
presence of obesity and a variety of diseases. In most
cases, such information has come from cross-sectional
studies of groups of people of different ages. On such
bases, it has been recognized that diabetes mellitus,
rheumatoid arthritis, and heart disease, increase in
incidence with advancing age. The appearance of some of
these conditions has been associated with obesity (Society
of Actuaries, 1959). That body weights increase until the
seventh decade and then decline has been demonstrated by
Montoye et al. (1965). This decline in body weight after
age 70 could be the result of the early death of overweight
individuals or an actual loss of weight in later life.
Even when body weight remains "normal" among older indi-
xriduals, there is suggestive evidence that these people
aaccumulate body fat at the expense of their lean body mass

(Skerjl et al., 1953). A decrease in lean body mass may

309

310

result in a decline in basal metabolic rate, thus influ—
encing the caloric requirements of the older individual.
Two biochemical parameters which frequently undergo
changes in later years are the glucose tolerance curve and
serum cholesterol. In that these clinical changes may,
in younger individuals, be reversed with a loss of weight,
it might be suggested that the accumulation of body fat in
aged adults could be responsible for the age changes in
glucose tolerance and serum cholesterol.
To further examine the relation between anthropo-
metric measurements, biochemical parameters, and age, the
survivors of a sample of 103 women from Lansing, Michigan,

previously studied in 1948, were re-examined.

Methods of Procedure

 

Procedures of sample selection and data collection

in 1948 (Chapter II, pp. 92-93) and re-examination in 1972

(Chapter II, pp. 93-95) have been described previously.

Anthropometric information recorded in 1948 included body
height and weight; however, actual measurements were avail-
able for only six of the 20 subjects who participated in
the physical evaluation in 1972. The remaining 12 subjects
were, in 1948, asked about their current height and weight.
Serum cholesterol and glucose tolerance were not measured
in 1948.

Anthropometry: In 1972, anthropometric measurements

were performed in the Olin Health Center on the morning of

311

testing, immediately prior to lunch (specific measurements
recorded may be found in Appendix E-l).w Subjects were
weighed in their underclothing, without shoes, and weight
recorded to the nearest quarter pound. Stature was measured
by a cross bar on the scale, and recorded to the nearest
eighth inch. Other body measurements (i.e., skeletal
widths, skinfold thicknesses, circumferences) were per-
formed according to the procedures outlined by the Com-
mittee on Nutritional Anthropometry, National Research
Council (Keys et al., 1956). Skeletal widths were deter-
mined using a bow caliper and recorded to the nearest mm.
A Lange skinfold caliper (pressure at 10 g/mm) was used to
measure skinfold thicknesses to the nearest tenth of a mm.
Circumference measurements were obtained with a steel tape
and recorded to the nearest mm.

Glucose Tolerance: Blood for the determination of
fasting glucose and insulin was drawn at the Olin Health
Center on the morning of testing, following a lZ-hour fast
(chemical methods may be found in Table V-l). The glucose
load was in the form of a high carbohydrate breakfast
(composition of meal may be found in Appendix E-2) which
provided 50-60 grams of carbohydrate. It was administered
to 19 subjects who submitted to the clinical evaluation.
The remaining subject, aged 69, followed a rigid dietary
Pattern as a result of medication to control myasthenia

gravis, and was omitted from this phase of the study.

312

Postprandial blood samples were taken two hours after the
subjects finished eating the meal; glucose and insulin
levels were determined.

Serum Cholesterol: Analyses were performed on
blood samples obtained following a lZ-hour fast (chemical
method may be found in Table V—l).

Relative Weight: In that the 20 women examined were,
in 1948, aged 40 to 61 years, relative weight for that
year was calculated according to height-weight tables com-
piled by the Society of Actuaries (1959). Since those
tables do not include information for individuals above
the age of 69, relative weights in 1972 were derived from
the height-weight tables of Americans aged 65 to 94 years,
published by Master et al. (1960).

Statistical procedures applied to results included

analysis of variance and correlation-regression methods.
Results
Anthropometric Measurements

Standing Height.--Loss of body stature has fre-

 

quently been associated with advancing age. Among the
Lansing women standing height when measured in 1972 was
Significantly related to age (r = -0.600, n = 20, p < .01).
Stature decreased by 0.27 inches per year in these indi—
Viduals who at the last examination ranged in age from 64

to 85 years. When subjects were compared by decade

 

313

interval (individual values for all anthropometric measure-
ments may be found in Appendix E-3), mean standing height
equalled 63.44 inches for those aged 64 to 69 years, 61.99
inches for those aged 70 to 79 years, and 59.16 inches for
women aged 80 or above. For the six subjects whose height
was actually measured in 1948, changes in body stature over
the 24-year interval were calculated. Two subjects aged 81
and 85 years lost 1.35 and 3.88 inches in height. A lesser
decline in stature was observed among three subjects aged
71, 75, and 77; for them losses were 0.92, 0.64, and 0.20
inches. One subject, 67 years of age, lost 0.50 inches in

height between 1948 and 1972.

Skeletal Widths.--The bone widths of these women

 

are expressed by decade interval in Table VI-l. Mean bi-
acromial measurements differed by only one cm between the
youngest and oldest subjects. Slight changes in bi-iliac
and chest widths were observed among the various age groups.
Bi-iliac width equalled 31.34 cm among the women with a
mean age of 66.9 years; this value dropped to 28.65 and
28.93 cm, among the women aged 74.4 and 81.8 years.
Similarly, the oldest subjects had decreased chest widths

as compared with the two younger groups.

314

 

 

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315

Skinfold Thicknesses.--Skinfold thicknesses were

 

determined at various anatomical sites as measures of body
fatness. As noted in Table VI-l, subcutaneous fat measure-
ments were lower in the older women. A considerable dif-
ference in fatness of the upper arm existed between women
below the age of 80 years and those who had reached or
surpassed this age. The triceps skinfold was less by
about 20 percent in the oldest subjects as compared with
the two younger groups, with a greater difference noted

in the biceps measurement. This skinfold decreased from
16.72 mm, observed among the women in the eighth decade,
to 9.92 mm in those aged 80 to 85 years. None of these
differences, however, were statistically significant. In
contrast, the degree of subscapular fat as measured in

these women remained relatively constant throughout all age

groups.

Body Circumferences.--Other measurements sometimes

 

used to obtain an estimate of the degree of body fatness
are body circumferences. A similar trend of decreasing
fatness among the older women was observed with body cir-
cumferences (Table VI-l). The change in the circumference
0f the upper arm parallels that noted in the triceps and
biceps skinfold thicknesses. The minimum waist and maximum
hip measurements also tended to be lower in the oldest

‘WOmen; however, none of these differences were significant.

316

Body Weight.-—Body weight is the physical parameter

 

used most commonly in a general assessment of nutritional
status. In these older women, body weight was evaluated
in terms of the relative degree of fatness of the individ-
ual, corrected for height and age (Master et al., 1960).
Contrary to what might have been anticipated, only 30
percent (6) of the Lansing subjects were within 10 percent
of average weight for their height and age (Table VI-2).
In contrast, four of the women were 20-39 percent over-
weight and five other individuals were more than 40 per-
cent above their average weight. The latter group had
body weights of approximately 200 pounds. Alternatively,
two of the subjects were markedly underweight, weighing

about 35 percent less than would be expected for their

Table VI-2.--Relative Weight Classifications of Twenty
Older Women Examined in 1972.

 

 

Classificationa Percent of Subjects
> 20% Underweight 10% (2)b
ll—20% Underweight 10% (2)
i 10% Average weight 30% (6)
11-20% Overweight 5% (1)
21-39% Overweight 20% (4)
:_40% Overweight 25% (5)

g

a
According to Master et al., 1960.

 

Number of subjects.

317

height and age. Among the Lansing subjects, body weight
was not related to age.

Inasmuch as obesity is a marked public health
problem in this and other countries, it is of interest to
know what fluctuations in body weight, if any, occur within
an individual in later life. In Table VI-3 are tabulated
the changes in body weight from those values reported by
the subjects in 1948. Seven subjects have lost at least
ten pounds of body weight, whereas six individuals have
gained at least this amount. One woman, aged 75, lost a
total of 75 pounds between 1948 and 1972. Alternatively,
the body weights of four subjects weighed in 1972 varied
less than five pounds from the value recorded in 1948.

Weight gain or loss was not always related to the
age of these older subjects. Those women who had lost at
least ten pounds in body weight between 1948 and 1972
included two individuals aged 69, two aged 75, and three
others aged 73, 81 and 85, with a mean age of 75.3 years.
A weight gain of ten or more pounds was noted in subjects
64, 68, 69, 75, 77 and 81 years of age, with a mean of
72.3 years. Although these values do not differ signifi-
cantly, it might be pointed out that two of the seven
subjects who lost weight were among the oldest women
Studied. In that average weights (from height-weight
tables) are lower for individuals above the age of 70,

the relative weight of the subject, aged 81, who

 

 

318

 

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320

experienced a weight loss of about 25 pounds between 1948
and 1972, was practically unchanged. Body stature also
decreased in the majority of these subjects over the 24-
year interval. On the other hand, one-half of the indi-
viduals who gained weight over this time interval, were in
the youngest age group.

Marked gains or losses in body weight are some-
times associated with a change in health status. Among the
Lansing women, no consistent pattern could be discerned.
One subject, aged 69, who lost nearly 20 pounds in body
weight between 1948 and 1972, has myasthenia gravis,
requiring constant medical supervision. Another woman,
aged 75, whose body weight also decreased by about 20
pounds, recovered rapidly from major surgery a few years
prior to the 1972 study, and works part-time, caring for
an invalid. Weight gain, on the other hand, was associ—
ated with diagnosed hypertension. Body weight in 1972 was
highly correlated (r = 0.772, n = 20, p < .01) with body
weight in 1948.

One factor of concern in respect to obesity is the
possible relation of nutrient intake to the development of
this condition. Neither absolute nor relative body
weight in 1972 was related to energy intake in either 1948
or 1972. FUrthermore, the amounts of the various macro—

nutrients in the diet were not associated with body mass.

321

Relationships Between Anthropometric
Measurements and Body_Weight

One problem in the assessment of nutritional status
in older individuals is that a simple physical measurement
to identify obesity is still to be defined. For this
reason it is of value to examine the relationship between
physical measurements and body weight. In Table VI-4 are
listed the correlation coefficients indicating the strength
of the relationship between the various physical measure-
ments and body weight. Skeletal measures at the bi-
acromial and bi-iliac levels would appear to be the least
reliable, whereas the chest width showed a higher corre-
lation with body weight. Skinfold thicknesses, especially
when measures taken at several sites were added together,
were highly related (r = 0.948, n = 20, p < .001) to body
weight. For women of this age, however, body circumferences
would seem to be of equal or greater value for prediction.
Circumferences of the upper arm and maximum hip showed the
highest correlations with body weight of any measurements

chosen.

Basal Metabolic Rate

 

Basal metabolic rate, associated with lean body
mass, has been known to decrease in older subjects, thereby
contributing to the lowering of the energy requirement in
later years. Inasmuch as caloric intake was relatively

low (mean caloric intake = 1297 kcal) among the Lansing

322

Table VI-4.--Relation of Anthropometric Measurements to
Body Weight of Twenty Older Women Examined

 

 

in 1972.
b r t
Skeletal widths
Bi-acromial (cm) +9.168 +0.638 3.517
Chest (cm) +9.372 +0.844 6.664
Bi-iliac (cm) +7.255 +0.657 3.696
Skinfold thicknesses
Triceps (mm) +3.43l +0.889 8.240
Biceps (mm) +4.146 +0.922 10.131
Subscapular (mm) +4.953 +0.772 5.159
Sum-skinfolds (mm) +1.617 +0.948 12.676
Circumferences
Upper arm (cm) +6.364 +0.964 15.348
Minimum waist (cm) +2.820 +0.9ll 9.392
Maximum hip (cm) +2.429 +0.955 13.322
Calf (cm) +4.120 +0.766 5.060

 

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323

subjects, estimates of the basal metabolic needs of these
women were examined. An estimate of the basal metabolic
rate of each was calculated according to the surface area
equation and Mayo Foundation standards for older individ—
uals reported by Berkson and Boothby (1936). The derived
values, based upon height and weight, are tabulated in
Table VI-S. For 13 of the women (65%) the calculated
basal energy needs were either less than the reported
caloric intake or within 100 kcalories of reported intake.
The calculated basal requirement was, for seven individuals,
214 to 904 kcalories above the reported energy intake.
Body composition is one factor which may influence basal
energy needs; a high degree of body fat with reduced lean
body mass could lower the energy requirement. Four of the
seven subjects who appeared to consume fewer calories than
required for basal needs were 40 percent or more above
average weight; two others were between 20 and 40 percent
above average weight.

Another factor which may influence caloric needs
is level of physical activity. Subjects were rated as
either relatively active (i.e., those who garden and care
for lawns, have part-time employment, provide care for
semi-invalid relatives, participate in hospital volunteer
work, bicycle in Florida, etc.) or inactive (those who,
aside from light housekeeping, spend their time primarily

reading or watching television). Although this subjective

324

Table VI-5.--Basa1 Metabolic Requirements of Twenty Older
Women Examined in 1972.

 

 

. Age Relative a Calorig
Subject (yrs) Wigggt BMR Ingage
202 81 100.6 1187* 1179
206 80 100.9 1183* 969
207 66 90.0 1297 1212
208 73 65.4 1018* 1173
212 75 143.8 1677 1840
213 75 149.1 1606 1190
214 81 122.8 1422 1671
218 69 95.5 1382 1323
221 64 126.6 1584 1728
223 71 110.3 1350 2153
224 68 145.0 1655 1299
225 77 161.2 1510* 606
226 85 114.3 1191* 1367
228 64 82.0 1460 1439
232 75 126.4 1511 1146
233 67 152.0 1654* 1234
235 69 66.2 1115 1815
239 74 85.1 1176 1188
241 75 125.0 1477 1129
242 69 99.1 1372 1327

 

:According to Berkson and Boothby, 1936.

Number of food records available for each subject may be
found in Appendix C-2.

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325

judgment was not used in a statistical evaluation, it
might be observed that three of the seven subjects with
lower caloric intakes than would be anticipated from basal
calculations, were inactive. Alternatively, 10 of the 14
women who consumed at least as many kcalories as deemed

necessary for basal needs (: 100), were physically active.

Glucose Tolerance

 

Carbohydrate Challenge.-—One characteristic noted

 

frequently among aging populations is a change in glucose
tolerance. A modified test of glucose tolerance was per-
formed on the Lansing women, using a breakfast meal con-
taining 50-60 grams of carbohydrate. About one-half of
the carbohydrate was supplied by table syrup, which,
unfortunately, was not well received by several of the
subjects. Four women consumed less than 40 grams of car-
bohydrate; carbohydrate intakes ranged from 34 to 67 grams.
Inasmuch as postprandial glucose and insulin values could
be a function of the amount of carbohydrate ingested, this
relationship was investigated. Among these women neither
postprandial glucose (r = -0.258, n = 19) nor postprandial
insulin levels (r = 0.192, n = 19) could be predicted from
the known amount of carbohydrate ingested. Therefore, all
values were included in the following calculations despite

existing differences in the carbohydrate challenge.

11'

326

Fasting and Postprandial Glucose and Insulin.--The

 

fasting and postprandial blood glucose and insulin values
are shown in Table VI-6 (mean values by age cohort may be
found in Table VI—7). According to accepted standards
(Davidsohn and Henry, 1969; Reed et al., 1972) fasting
blood glucose levels of 107 to 110 mg/100 ml represent the
upper limit of normal. Two of the Lansing women approached
these levels with blood values of 103 and 105 mg/100 ml.
The individual for whom the fasting level was 159 mg/100 ml
was being treated for diabetes mellitus at the time of the
study. For the other 16 subjects, fasting blood glucose
levels ranged from 65 to 91 mg/100 ml. Fasting glucose
values were not related to age.

By known standards (Davidsohn and Henry, 1969),
blood glucose levels two hours following a 100 gm glucose
challenge should have returned to 110 mg/100 ml, with values
between 110 and 120 mg/100 ml indicative of the need for
further testing. A postprandial blood glucose value in
excess of 120 mg/100 ml is very likely an indication of
diabetes (Davidsohn and Henry, 1969). These standards,
however, have been derived from clinical evidence obtained
with young adults. Whether such standards are also
applicable to older individuals is a matter of concern.
Postprandial blood glucose levels among the Lansing women
ranged from 70 to 163 mg/100 ml. By the usual criteria of

jUdgment, about one-half of the Lansing women showed

327

 

 

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330

impaired glucose tolerance. Although five of the nine
women with above-normal postprandial glucose levels had
values only mildly divergent from normal (between 112 and
120 mg/100 ml), five subjects had blood glucose levels
above 125 mg/100 ml. One individual (blood glucose = 163
mg/100 ml), on the basis of this test, would appear to be
diabetic. For no subject, however, was glucose detected
in the urine. In the Lansing women, postprandial blood
glucose levels were associated with age (r = 0.456, n = 19,
f>==.05). Mean postprandial blood glucose values equalled
100.7, 119.9 and 118.0 mg/100 ml among women in the
seventh, eighth and ninth decades (Table VI-7).

In contrast to the divergence in fasting glucose
levels observed in the Lansing women, fasting insulin
values varied only slightly, ranging from 11 to 20 uU/ml.
Fasting insulin levels were not related to age. Post-
prandial insulin measures, on the other hand, ranged from
20 to 143 uU/ml. Postprandial insulin levels were not
significantly related to postprandial blood glucose levels;
neither did postprandial hormone levels relate to age.
IAlternatively, a high degree of correlation was observed
between fasting and postprandial insulin levels (r = 0.743,

n = 19, p < .01).

Glucose Tolerance and Body Weight.--Aberrations in
the glucose tolerance curve have been associated with an

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postprandial blood glucose and insulin levels were examined
in respect to relative weight in both 1948 and 1972. The
body weight of the Lansing subjects did appear to influence
their response to a carbohydrate challenge. Fasting glu-
cose levels were not related to relative body weight in
either 1948 or 1972; this was not true, however, for post-
prandial glucose levels (Table VI-8). That biochemical
parameter was significantly related to relative body weight
in 1948 (r = 0.484, n = 19, p < .05), although it exhibited
110 such correlation with relative body weight in 1972.
Findings were similar for both fasting and postprandial
insulin levels. Relative weight in 1948 was a significant
predictor of both fasting and postprandial insulin levels.
Alternatively, relative measures of body weight in 1972
were significantly related to fasting insulin levels only,
although relative weight in that year did show some associ-

ation with postprandial insulin response (p < .07).

Glucose Tolerance and Nutrient_1ntake.--Previous
intake of carbohydrate has been known to influence the
glucose tolerance curve. Dietary intakes of the macro-
nutrients in 1972 were examined in relation to the indices
of glucose tolerance. Nutrient intake did not appear to
influence the fasting glucose level in the Lansing sub-
jects, as this parameter was not significantly related to
dietary intake, although values did tend to be higher in

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333

fat in 1972. Neither postprandial glucose levels, nor

fasting or postprandial insulin levels, were related to the

1972 dietary intakes.

Serum Cholesterol Levels

One biochemical parameter frequently associated
with aging, obesity, and the development of cardiovascular
disease, is serum cholesterol. Among the Lansing women,
serum cholesterol values ranged from 184 to 362 mg/100 ml
(Table VI-9). Age may not always be a factor influencing
serum cholesterol levels in older women, as in these sub-
jects no significant relation was observed; however, serum
cholesterol values did tend to be higher among the oldest
subjects. Similarly, body weight in either 1948 or 1972
had seemingly no influence on serum cholesterol. Serum
cholesterol values have, however, been suggested to be a
function of the dietary intake of the individual. This
would appear to be true for the Lansing subjects (Table
VI-8), as the level of calories (r = 0.479, n = 20,
p < .05), fat (r = 0.469, n = 20, p < .05) and carbohydrate
(r = 0.497, n = 20, p < .05), consumed in 1948, were posi—
tively related to this serum value. The only nutrient in
the 1972 diets significantly related to serum cholesterol

was protein (r = -0.474, n = 20, p < .05).

334

Table VI-9.-—Serum Cholesterol Levels of Twenty Older Women
Examined in 1972.

 

 

Subject Age Serum Cholesterol
Number (yrs) mg/100 ml
202 81 240
206 80 238
207 66 200
208 73 212
212 75 200
213 75 210
214 81 325
218 69 300
221 64 .205
223 71 222
224 68 255
225 77 248
226 85 315
228 64 214
232 75 240
233 67 255
235 69 184
239 74 255
241 75 275

242 69 362

 

 

 

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Discussion

 

Changes in Physical Measure-
ments With Age

Changes in body measurements are known character-
istics associated with the aging process. Among the
Lansing women only one physical measurement changed sig-
nificantly with advancing years; standing height decreased
as a function of age. A loss of stature by aging individ-
uals has been reported by other investigators. Data from
855 cadavers examined by Trotter and Gleser (1951)
revealed significantly lower stature among the older indi-
viduals; this finding was not associated with a variance
in the length of the long bones (i.e., femur, tibia).
Although in that study average stature and lengths of the
individual bones measured were relatively constant up to
the age of 79, a large decline in both stature (8.2 cm)
and femur length (1.5 cm) occurred in females between the
eighth and ninth decades. In the Lansing subjects, mean
height was lower by 7.1 cm for this age interval.

Other workers studying living populations have
reported similar trends. Wessel et al. (1963), in a study
of women from 20 to 69 years of age, found differences in
stature among the various age groups which could be
attrdlsuted to changes in trunk measurements, suggesting
vertebral and disc changes or osteoporotic degeneration.

Other investigators (Ohlson et al., 1956) have pointed out

336

the wide variation among individuals in loss of stature.
That study of 12 women between the ages of 48 and 77 years
was continued over a period of a decade. Two individuals
in the group exhibited no change in height, with losses
among the others varying from 0.5 to 2.0 cm. In the Lansing
study a greater variation, with losses of 0.51 to 9.86 cm,
was observed among the six Lansing women measured in both
1948 and 1972. The greatest loss occurred in the subject
who, in 1972, was the shortest in stature and 85 years of
age. In this study, however, the time interval equalled
24 years.

Skeletal widths or measures of the body frame also
tend to change with the aging process in women, although
the magnitude and direction of such changes would appear
to depend upon the particular population studied. Wessel
et al. (1963) observed a continuing decrease in bi-acromial
width between age 20 and 69, whereas the bi-iliac width
increased with age in their subjects. The women aged 60
to 69 had narrower shoulders, broader hips, and wider
chests, than did the younger subjects. In contrast, other
investigators (Skerlj et al., 1953) who examined 84 women
ranging from 18 to 67 years of age suggested that the
younger women tended to have broad frames, whereas the
older groups were narrow in build. According to that
author, the more narrow build of the oldest subjects could

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their growth period. In the Lansing study, bi-acromial
widths decreased slightly with age, with the narrowest
shoulder width (29.4 cm) being observed in the oldest
subject, aged 85. Bi-iliac widths also tended to be lower
in the older age groups, equalling 31.34 cm among those
aged 60-69 compared with a value of 28.93 in those aged

80 or above. Another report combining data obtained from
both Michigan and Minnesota women (Ohlson et al., 1956)
showed a decrease in bi-iliac width from 31.1 cm in those
aged 60 to 69 to 30.6 and 30.9 cm in those aged 70 to 79
and 80 to 89, respectively. Generally, the skeletal widths
of the Lansing women fell within the range of values
reported by other investigators.

Another factor in addition to age which has been
shown to influence skeletal structure is body weight.
Ohlson et a1. (1956) reported that bi-iliac width increased
from 26.7 cm in underweight women to 28.3 and 33.0 cm in
average-weight and overweight women. In the Lansing study,
mean chest widths tended to be greater (2.0-2.5 cm) than
the values reported by Ohlson et al. (1956) for women of
similar age; however, five of the Lansing women were more
than 40 percent above their average weight.

Other body measurements known to change with
advancing age are skinfold thicknesses. All skinfolds
measured were lowest among the Lansing subjects aged 80 or

above. When the Lansing values were compared with those

338

suggested by other investigators for women of similar age,
differences were observed in respect to the particular
skinfold site. The triceps measurement in the Lansing
subjects aged 64 to 77 years was similar to that found by
Young et a1. (1963) in subjects between the ages of 60 and
69. These values were 27.00 and 28.50 mm in the Lansing
women aged 64 to 69 and 70-79, respectively, compared with
28.0 mm, reported by Young and coworkers (1963).

In contrast to the triceps skinfold found to be
similar in the Lansing and New York women (Young et al.,
1963), the subscapular skinfold thickness differed markedly
in these two subject groups. The subscapular value
equalled 22.55 mm in the women studied by Young and co-
workers (1963), whereas this measurement was 14.00 to
15.25 mm among the Lansing women of similar age. Alter-
natively, other investigators (Wessel et al., 1963)
reported a scapular skinfold thickness of 14.0 mm in their
subjects between the ages of 65 and 69, a finding in close
agreement with the Lansing study. Those investigators
reported that all skinfold thicknesses decreased beyond
the age of 60, with marked changes in the scapula.

The reported decline in skinfold thicknesses in
women after the age of 60 suggests that as the degree of
fatness in the female body changes, so does its pattern of
distribution. As was concluded by Young et al. (1963a),

fat in the older woman is deposited on the chest, sides,

339

waist and back, with a lesser amount on the extremities.
Among those subjects the measurement showing the highest
correlation with body density (determined by underwater
weighing) was abdominal circumference at the level of the
umbilicus. Similarly, in the Lansing study, maximum hip
girth was closely correlated with body weight. The high
correlation of the abdominal measure to body weight would
seem to confirm the suggestion of Skerjl et a1. (1953)
that the fat accumulated by the female body during later
maturity is inner fat. Inasmuch as the total weight of
those subjects did not change, the addition of inner fat
seemed to be occurring at the expense of other tissues.
Problems in Assessing Body
Fatness in Older Pe0ple

The prediction of body fatness in older people by
the measurement of skinfold thicknesses presents many
difficulties. One such problem is the concern that skin-
fold measurements may, in older age groups, yield less
reliable values. Brozek and Kinzey (1960) found upon
studying skinfold compressibility in males from 20 to 69
years, that the degree to which skinfolds are compressed
by a given pressure, decreases with age. This decrease
in compressibility could effectively exaggerate the
reported trend toward increased subcutaneous fat measure-
ments in older subjects. The reliability of the skinfold

thickness measurement is complicated further by the fact

340

that this change in compressibility is not uniform over
the body surface. Those authors (Brozek and Kinzey, 1960)
noted significant changes in the measures at the scapula
and waist. In the Lansing study, the author noted a
tautness in the skin at the scapula level, making it more
difficult to lift the skinfold. This could have been the
result of tenseness on the part of the subject. For the
20 Lansing women, the scapular skinfold was less highly
correlated with body weight than were the arm skinfolds.
Another problem relating to the accuracy of skinfold
measurements may result from rapid weight loss. Edwards
(1950) noted a decrease in tissue elasticity among his
patients who had lost in excess of 10 to 15 pounds.
Another consideration in the use of skinfold
thicknesses to estimate the degree of body fat is the
selection of the particular skinfold measurements to be
used. Garn (1955) suggests that relative fat patterning
is an individual characteristic. This pattern would
appear to possess some degree of permanence over time, as
men who lost as much as 28 kg of body weight still main-
tained their former pattern. According to Seltzer and
Mayer (1967) the triceps skinfold would seem to be a more
accurate measurement for the estimation of body fat than
the scapula measurement. They observed an absence of
marked fat depots at the subscapular region, whereas the

triceps showed excessive adipose tissue. In their series

341

of obese women, the triceps fold was greater than the sub-
scapular fold in 83 percent of the subjects. This trend
was also apparent in the Lansing study, as for 19 of the
20 subjects, the triceps measure exceeded that of the
scapula.

The original intention of the author was to cal-
culate the percent body fat of each subject using measured
skinfold thicknesses. Durnin and Rahaman (1967) have
derived a formula for this purpose which utilizes skinfold
thicknesses measured at four sites: the triceps, biceps,
scapula and waist. This formula was derived, however,
from measurements on young adults. Because of objections
from several subjects, the waist skinfold measurement was
dropped from the protocol. Unfortunately, a satisfactory
procedure for determining the percent of body fat from the
available measurements could not be found. Such equations
as have been derived are based upon measurements of adoles-
cent females or adult women aged 30 to 50 years. An
equation reported by Seltzer and Mayer (1967), developed
from the data of Steinkamp et a1. (1965), utilizes the
triceps skinfold for the calculation of body fat; however,
spurious values resulted from this method. One subject in
the Lansing study who weighed 197 pounds (relative weight
equalled 143.8), had, according to this calculation,
approximately 27 percent fat in her body. This value is

less than the average of 44.6 percent, reported by Young

 

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342

et a1. (1963) as the level of body fat in her normal-
weight subjects aged 60-70 years. This would suggest that
methodology based upon younger females is not necessarily
applicable to aged individuals. As noted by Wessel et al.
(1963) all skinfold measures decrease after the age of 60
years. The unreliability of skinfold thicknesses among
older subjects would suggest that increased attention be
directed toward circumference measurements as indicators of
body fat. Among the older women studied by Young et al.
(1963) the measurement showing the highest correlation
with body density was the abdominal circumference at the
level of the umbilicus (r = 0.717). Similarly, in the
Lansing women, the maximum hip circumference showed a high
correlation (r = 0.954) with body weight. Further work is
needed to define the relationships between envelope
measurements and degree of body fat in older subjects.

Changes in Body Weight in
Older People

 

 

One striking observation in the Lansing study was
the large number of subjects who were markedly overweight.
Other evidence suggests a decrease in body weight among
individuals of advanced age. Montoye and associates (1965)
observed a decrease in body weight after the age of 60
among the residents of Tecumseh, Michigan. Similarly,
Master and coworkers (1960) found, upon examining data

obtained from 2,694 women between 65 and 94 years of age,

343

that average weights decreased with advancing years. This
was not always true among the Lansing women. Five of the
eight women aged 70 to 79 were at least 20 percent above
average weight, with three of the five at least 40 percent
above that value.

Despite the association between degree of overweight
and mortality as established by life insurance statistics,
overweight persons can live to an advanced age. Among 200
patients over 65 years of age who had been referred to an
outpatient nutrition clinic (Skillman et al., 1960), 68
percent were more than 10 percent above their "desirable"
weight (weight standards used were not given). Eight per-
cent of those examined were more than 10 percent under-
weight, whereas the remainder were of normal weight. It
should be noted, however, that the subjects in that study
had been referred to a nutrition clinic and were therefore
not representative of the general population. Further
evidence of overweight among the aged comes from the work
of Pomeranze (1957) who pointed out that 19 percent of 120
patients over 75 years of age were, on the basis of skin-
fold thicknesses, considered obese. As concluded by that
author, this does not mean that all obese persons live to
old age, but does indicate that obesity does not neces-
sarily preclude longevity. The majority of those obese
subjects indicated that they had been obese since early

childhood; to them, excess weight had been synonymous with

344

good health. Two women had lost and regained as much as 20
pounds on at least two occasions during their lifetime.

The survival of overweight individuals is confirmed
by the Lansing study in which several women were signifi-
cantly overweight since middle age. These subjects were
living independently and, except for one, enjoyed reasonably
good health. The woman, aged 69, with the highest body
weight, was diabetic. Another individual had severe
arthritis which limited her activity. The other obese
subjects were, however, relatively active. Two individuals,
aged 75 years, and more than 20 percent overweight, worked
part-time to supplement their income; one did laundry and
ironing for her neighbors and the other cared for an
invalid several days each week. Another obese woman,
weighing 197 pounds, had a large lawn and flower garden,
for which she was responsible. As suggested by Pomeranze
(1957), the nutritional inadequacies which frequently
result from repeated attempts at weight reduction may be
more harmful than a static obesity.

Although the majority of the obese Lansing sub-
jects had been overweight throughout adulthood, this is
not always the case among older people. Hollifield
et al. (1959) found that almost one-half of their female
subjects who were overweight gained this weight after
reaching the age of 65. Three of the Lansing women above

the age of 65 had gained at least 20 pounds since the 1948

345

survey. Whether this change in weight was gradual or

rapid in onset, is not known. Considerable weight loss

has also been associated with advancing age. Hollifield

et al. (1959) noted that one-third of their normal-

weight subjects had been obese at some earlier age. Five

of the Lansing women lost at least 20 pounds or more between
1948 and 1972.

The control of body weight over long periods of
time is an area requiring further study. Of considerable
interest are the seven Lansing women whose body weight
changed by less than 10 pounds between 1948 and 1972.
Whether this relative constancy in body weight was the
result of internal mechanisms, conscious efforts at weight
control, or a combination of both, is not known.

Problems in Estimating Energy
Balance in Older People

 

 

That the caloric needs of the individual decrease
with advancing age has been well established. This
decline relates to changes in metabolic rate, as well as
differences in physical activity (McGandy et al., 1966).
Twelve of the 20 Lansing subjects appeared to be consuming
sufficient energy to meet both metabolic and activity
requirements, as total caloric intake was greater than
or approximately equal to calculated basal needs. Three
Of the twelve were relatively inactive; for them, the total

energy requirement may be very close to basal needs.

346

In contrast, for seven individuals, a discrepancy
existed ranging from 214 to 904 kcalories, between reported
caloric intakes and calculated basal needs. This differ-
ence could relate to several factors. The most obvious
is that these women may have underestimated the quantities
of food consumed. One individual reported a mean caloric
intake of 606 kcalories; the value reported for her in
1948 was 812 kcalories. Her relative weight was 161.2,
although she gained only 15.4 pounds since 1948 when she
was last seen. Inasmuch as she was markedly limited in
movement because of severe arthritis, her total energy
requirement was very likely approximately equal to the
basal requirement.

A second factor which might explain the difference
between reported and calculated energy needs is error in
the calculation of the basal requirement. When using body
weight as an estimate of mass, one concern is the actual
amount of lean body tissue in relation to body fat. The
relative decrease in vital tissue and accumulation of
internal fat as a consequence of aging, has been mentioned
previously. Standard equations have been developed with
subjects of average weight; yet, most of the evidence
suggests that basal metabolic rate is related more closely
to lean body mass. Actually, when calculated on that
basis, the difference in basal metabolic needs for men and

women (at least 20 years of age) or young and old adults,

 

 

me
We
60

Alt

347

disappears (Shock et al., 1963). Whether the relatively
high basal requirements derived for those individuals
above average weight are valid, is still to be established.
The question of basal metabolic needs in aged
females was studied extensively by Benedict (1935). That

investigator concluded that the average value for total

 

heat production in women aged 66 or above, was approximately
1000 kcalories, regardless of age and irrespective of body
weight. Furthermore, the predominant component of excess
weight is fat, which according to that author (Benedict,
1935), automatically lowers heat production per unit of
body weight. This reduction in heat production may be the
result of various factors--one of these is the lower heat
production of adipose tissue, another is the greater
insulating effect of the subcutaneous adipose tissue, thus
reducing the need for extra heat production. If it were
assumed that the basal energy needs of the Lansing subjects
were approximately 1000 kcalories, all but one would
appear to be in energy balance; recorded energy intakes
would reasonably approximate basal caloric needs.

Occasionally, in other studies, older women have
reported extremely low caloric intakes. In a recent
national survey (U.S. Dept. of Health, Education and
Welfare, 1972b), 9.2 percent of the women above the age of
60 were reported to have less than 750 kcalories daily.

Although the basal metabolic rate of the Lansing subject

348

who reported a daily intake of 606 kCalories (relative
weight = 161.2) was not determined, her energy needs may

not have been any greater than that low value. This is
suggested by a report from another investigator (Horton,
1975, personal communication) who observed a basal metabolic
rate of less than 600 kcalories in one of his subjects.

That woman, like the Lansing subject, was severely obese.
This would suggest that basal energy needs of the aged

obese may be significantly lower than would be anticipated
by standards now in use.

Evaluation of Glucose
Tolerance in Older People

 

 

The results obtained from the glucose tolerance
study of the Lansing subjects have many limitations.
Initially, the carbohydrate challenge (50 grams) given to
the subjects was considerably less than the 100 gram level
for which normal blood values have been standardized. The
100 gram challenge was rejected in that information regard-
ing the current health status of these older women was not
available prior to the test, increasing the risk of this
examination. Another factor to be considered is the form
in which the carbohydrate is administered. The usual
method employs a glucose solution which is rapidly
absorbed. In that the subjects were to have an active
morning including a physical examination, x-rays, etc., it

was decided that they should have some type of meal.

349

Inasmuch as 100 grams of carbohydrate represents a meal of
considerable bulk, a point of concern was the ability of
the subjects to consume this amount of food. On this
basis, a meal was selected which contained 50-60 grams of
carbohydrate, with 30 grams to be provided by two table-
spoons of a sugar syrup. A fact not anticipated was the
subjects' avoidance of the syrup. Four women consumed
only the French toast, leaving the syrup on the plate.
Consequently, carbohydrate intake among all subjects
varied from 34 to 67 grams. Furthermore, the carbohydrate
consumed was not pure glucose, but contained fructose as
well.

Emotional stress is known to adversely influence
the glucose tolerance curve. This could be a factor in the
blood glucose levels observed in the Lansing subjects.

Many of these women were visibly nervous with one so dis-
traught that she experienced a slight intestinal disturbance.
Uneasiness regarding the testing program was especially
common among those coming to the health center on the
morning of the test. Two women were concerned about their
husbands who were in poor health, being alone at home. In
addition, the women were allowed coffee with their break-
fast. Caffeine may influence blood sugar values. With
these limitations in mind, the glucose tolerance patterns
were examined in relation to age, nutrient intake, and body

weight.

350

Many investigators have described the effect of
age upon the ability of the organism to handle a glucose
load. This decrease in glucose tolerance appears to be
gradual and progressive throughout adult life (Andres,
1971). According to Gottfried and coworkers (1961),
studying 49 supposedly healthy subjects over 70 years of
age, carbohydrate metabolism is impaired in the majority
of older people. In that study, all individuals displayed
a "minimum to moderate" diabetic curve following a glucose
challenge. The criteria for diagnosis of this diabetic
tendency were not given. Similarly, Metz et al. (1966)
reported that 13 of their 18 elderly subjects given 100
grams of glucose by mouth had blood glucose levels above
130 mg/100 ml at the end of the two-hour period. Only
five of the 19 Lansing subjects had postprandial glucose
levels above 120 mg/100 ml. One explanation for this
reduced incidence of abnormality could be the degree of
carbohydrate challenge (50-60 versus 100 grams).

Examination of the various biochemical measures
in the study of glucose tolerance would suggest that the
fasting blood glucose level is the least affected by age.
This evidence comes from Burch and O'Meallie (1967) who
studied 77 healthy subjects over 65 years of age. Only
four of those individuals had fasting blood glucose levels
above 120 mg/100 ml. Those findings closely parallel the

Lansing results, in that fasting blood glucose was elevated

351

in only one subject. She had a fasting blood glucose level
of 159 mg/100 ml and was being treated for diabetes
mellitus at the time of the study. Further evidence that
fasting glucose levels do not change as rapidly as other
measurements comes from the work of Reed and associates
(1972). Screening 1,419 clinically normal adults indicated
that fasting glucose levels equalled 93 mg/100 ml in women
aged 50 years and over, as compared with 86 mg/100 ml,
observed in those aged 20 to 49 years.

The most common abnormality of glucose tolerance
observed in older subjects is an elevated two-hour post-
prandial blood glucose level. This was true for one-third
of the older subjects studied by Burch and O'Meallie
(1966). In the Lansing study abnormally high postprandial
glucose levels (above 120 mg/100 ml) were observed in one-
fourth of the women examined. Contrary to what might have
been anticipated, the five individuals with the abnormally
high postprandial glucose levels were not those who con-
sumed the highest levels of carbohydrate. Three subjects
with postprandial glucose levels of 127, 130 and 135 mg/
100 m1 ingested 40, 41 and 47 grams of carbohydrate,
respectively. Another woman whose postprandial glucose
level equalled 134 mg/100 ml consumed only 34 grams of the
test carbohydrate. The individual with the highest post-
prandial glucose level (163 mg/100 ml), however, did

ingest 67 grams of carbohydrate. Alternatively, seven other

 

352

women who had approximately 60 grams of carbohydrate for
breakfast had postprandial glucose levels between 70 and
117 mg/100 ml.

A comparison of the two-hour postprandial glucose
levels of the Lansing subjects with those obtained by
other investigators using a 50 gram test, revealed some
similarities. Among 345 English subjects ranging from 20
to 79 years of age (Diabetes Survey Working Party, 1963)
mean blood glucose in the oldest subjects, two hours
following the ingestion of 50 grams glucose, equalled 119
mg/100 ml, comparable to that found among the Lansing women
aged 70 to 85 years (values equalled 119.9 and 118.0 mg/
100 ml in subjects aged 70-79 and 80-85 years). The
increase in the two-hour blood glucose level among the
English subjects was approximately 3.5 mg/100 ml for each
succeeding age decade. The effect of age on the glucose
level at 120 minutes is less obvious when the glucose
load is relatively small. Inasmuch as mean postprandial
lolood glucose levels of older subjects commonly approach
«or exceed the upper limits of normality and might there-
fore be classed as diabetic, another author (Andres, 1971)
suggests that standards be adjusted to allow for age-
:related changes in response. Such a scheme would judge
an individual's performance in relation to that of his age

cohort rather than to those of younger individuals.

353

Blood insulin levels, both fasting and postprandial,
have also been reported to change as a function of age.
This suggestion comes from the work of Chlouversakis et al.
(1967) who observed a rise in fasting insulin levels from
7.3 uU/ml among subjects aged 20 to 39, to 10.8 and
16.1 uU/ml in the groups aged 40-59 and 60 years and
above, respectively. The fasting insulin value observed
among those individuals above the age of 60 (16.1 uU/ml
is comparable to the values of 14.8, 15.1, and 13.5
uU/ml found among the Lansing women in various age
groups. Alternatively Metz et al. (1966) reported a
range of 7 to 40 uU/ml in fasting insulin among his
subjects aged 67 to 87 years, whereas in the Lansing sub-
jects this value ranged from 11 to 20 uU/ml.

The postprandial serum insulin levels observed in
the Lansing women were compared with the report of
Chlouversakis et a1. (1967) who administered a 50 gram
«glucose challenge to 21 subjects above the age of 60.
bMean postprandial insulin levels equalled 29.9 uU/ml
for those individuals who had previously been screened for
ruanmal glucose tolerance. The range of values observed in
that.study was not given, nor was there any statistical
cavaluation. Mean postprandial insulin levels tended to be
higher among the Lansing subjects, equalling 41.0, 57.4,

and 35.8 uU/ml in those aged 60 to 69, 70-79, and 80—85

354

years of age, respectively. The Lansing sample, however,
included individuals displaying abnormal glucose tolerance.

There may be a difference in insulin levels of
older men and women. This suggestion also comes from the
work of Chlouversakis et a1. (1967) who reported that males
with normal glucose tolerance had a mean postprandial
insulin level of 31.2 uU/ml as compared with a value of
24.5 uU/ml, observed in normal females. This pattern was
reversed, however, among borderline diabetics; the post-
prandial insulin level for males was 36.4 uU/ml, whereas
that for females was 48.4. The two highest post-prandial
insulin levels observed in the Lansing subjects were
noted in one individual being treated for diabetes
mellitus and in another who demonstrated an elevated post-
prandial glucose level (163 mg/100 ml). The latter indi-
vidual would seem to require further testing to ascertain
the presence of diabetes.

In the Lansing study, parameters of glucose
tolerance were directly related to body weight. That an
excessive accumulation of body fat may result in impaired
carbohydrate metabolism has been suggested by various
investigators. West and Kalbfleisch (1966), studying
maturity-onset diabetes in various countries, found the
single common denominator to be the degree of body fat.
Similarly, Kalkhoff and Ferrou (1971) pointed out the

aberrations of glucose tolerance and exaggerated insulin

..1_

355

responses observed among obese patients as compared to
muscular overweight men.

Frequently, abnormalities in carbohydrate metabolism
observed in older people are reversible with weight loss.
This suggestion comes from the report of Goodman (1955) who
observed significant improvement in elderly diabetics upon
successful weight reduction. In contrast to this finding,
Brandt (1960) could find no correlation between impaired
glucose tolerance and weight gain in his older subjects.

At this time, the effect of long-term overweight on carbo-
hydrate metabolism is not completely understood. The
Lansing subject who exhibited a postprandial glucose level
of 163 mg/100 ml and accompanying insulin level of 143

uU/ml had, in 1948, a relative weight of 160.3. Although
she lost 75 pounds between 1948 and 1972, her glucose
response pattern was abnormal. Whether obesity-induced
aberrations in carbohydrate metabolism are always reversible
is a question requiring further study.

Little is known regarding the long-term influences
of dietary habits upon blood levels of glucose and insulin.
That dietary intake on days immediately preceding testing
can influence glucose tolerance has been documented. Conn
(1940) stressed the need for adequate dietary carbohydrate
(300 grams) prior to the study of glucose tolerance, to
insure the presence of adequate liver glycogen stores.

Conversely, diets high in protein and fat on the days prior

 

356

to testing may result in an abnormal response. None of the
Lansing women consumed 300 grams of carbohydrate daily,
according to the dietary records collected in 1972. This
dietary lack of carbohydrate could be a contributing
factor in the abnormal glucose tolerance patterns observed.
In older subjects, however, postprandial glucose
levels may not always relate to the previous dietary
intake. This suggestion comes from the report of Gillum
et al. (1955b) who examined 430 subjects over 50 years of
age. Postprandial glucose levels in those individuals
following a high carbohydrate meal (exact glucose content
not given) were unrelated to previous intakes of carbohy-
drate and protein. Among those women, however, blood
glucose values tended to be higher when total fat intake
was above 80 grams daily. In the Lansing study, fasting
blood glucose showed some positive relation to dietary
fat, although this was not true for postprandial values.

Serum Cholesterol Levels
in Older People

 

 

In males, serum cholesterol values have frequently
been related to the incidence of coronary attack (Keys
et al., 1971). Alternatively, high levels of serum
cholesterol among women do not always predispose one to an
early death from cardiovascular disabilities. This is
suggested by the fact that two of the Lansing subjects

above the age of 80, had serum cholesterol levels above

357

300 mg/100 ml. The general range of cholesterol values
among the Lansing women (184 to 362 mg/100 ml) was similar
to those observed by other workers. Women over 50 years

of age examined in San Mateo County, California (Gillum

et al., 1955) had serum cholesterol values ranging from

140 to 438 mg/100 ml, with a mean of 270 mg/100 ml.

Among midwestern subjects (Swanson et al., 1955) mean serum
cholesterol levels were 250 and 265 mg/100 ml for two
groups of subjects aged 60 to 69 years, and 251 mg/100 ml
in both groups aged 70 to 79 years. In that study, serum
cholesterol values declined progressively between the ages
of 50 and 80 years. A different response was observed in
the Lansing women in that mean values equalled 247, 233 and
280 mg/100 ml, in the seventh, eighth and ninth decades,
respectively. A recent report (Reed et al., 1972) indi-
cates that the normal range of serum cholesterol values

in women above the age of 60 is 182 to 353 mg/100 ml. In
that survey, the mean cholesterol value rose from 200 mg/
100 m1 among women aged 20 to 29, to 250 mg/100 ml among
those aged 60 or above.

Serum cholesterol levels in women do not seem to
be related to body weight. Gillum et al. (1955) observed
no association between serum cholesterol values and body
weight among their subjects. This finding was confirmed
by the Lansing results in which no relation was found

between body weight in either 1948 or 1972 and serum

358

cholesterol. Serum cholesterol values may be influenced
by past and present dietary intake, although conclusions
have differed in various studies. Dietary protein and fat
had little influence upon the cholesterol levels of the
midwestern women observed by Swanson et al. (1955). In
contrast to this finding, Gillum et a1. (1955) noted higher
serum cholesterol levels among those women with increased
intakes of fat. This observation was confirmed among the
Lansing women, for whom fat intake in 1948 was positively
associated with 1972 cholesterol levels. In the San Mateo
women (Gillum et al., 1955), a slight but positive corre-
lation existed between dietary protein and serum cholesterol.
The relationships between dietary intake in 1948
and serum cholesterol levels in 1972 which were observed
in the Lansing subjects deserve examination in future
studies. The number of individuals was small; however,
these results suggest that in women, serum cholesterol
levels may be established in middle age or before, and do
not respond to dietary changes thereafter. Whether this
might also be true in men has great implications in regard

to the treatment of hypercholesteremia.

Conclusions

 

Normal aging is accompanied by a loss in stature,
whereas skeletal widths do not appear to be influenced by
advancing age. Fat deposition on the extremities would

seem to decrease in advanced age, as evidenced by decreased

359

skinfold thicknesses on the arm. In older women fat may
be deposited on the trunk, as circumference measurements
were highly correlated with body weight.

Either weight gain or weight loss may occur from
middle to advanced age; however, overweight, in these
older women, did not necessarily predispose to an early
death.

Of all the measures of glucose tolerance, fasting
glucose levels are least affected by advancing age. Post-
prandial glucose and both fasting and postprandial
insulin levels are, in older women, positively influenced
by body weight. Among older women, serum cholesterol does
not appear to be related to age or body weight; this value
may relate to previous dietary intake of calories, fat,

and carbohydrate.

 

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388

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APPENDICES

APPENDIX A

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER II

APPENDIX A

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER II

Appendix A-l

 

Letter of Introduction to Survey Subjects

Last fall, Miss Eleanor Schlenker talked with you about a
health and nutrition survey. This is a follow-up of a
study in which you participated in the 1950's. At that
time, we secured records of the food you ate; you were
given a physical examination; and a variety of measurements,
such as your height and weight were made. These we would
like to repeat to determine whether there is any relation-
ship between the kind of diet you followed twenty years ago
and your present health. We hOpe that, as a result of this
study, we will have factual information which will indicate
the kinds of foods younger people Should eat to ensure good
health throughout their lives. The importance of your
c00peration in such an endeavor needs no elaboration.

Sometime within the next few days, Miss Schlenker will
visit you to explain this study in greater detail and will
answer any questions you have. At that time, She will
arrange for the record of your food intake and a few other
items of needed information.

We sincerely appreciate the interest you have Shown in this
PrOject by your original contribution and now by your will-
ingness to participate in the follow-up study. As a result
Of your partiéipation in this study the young people in
Your family may be better able to choose those foods and
living habits which Should make it possible for them to
enjoy a healthy and exuberant future.

392

393

Should you wish any further information about the study
prior to Miss Schlenker's visit, please call the Department
of Food Science and Human Nutrition at 355-7730.

Thank you for your assistance in this study.

Sincerely yours,

Dr. Dena Cederquist
Professor of Nutrition

DC/ps

394

Appendix A-2

Dietary Interview Schedule
For Survey Subjects

 

 

 

 

 

 

Name: Subject Number:
Address: Date:

Time:
Phone:

 

NUTRITIONAL STATUS OF OLDER WOMEN

We are interested in the kinds of foods that you
usually eat. If your food choices have changed in the last
few years, we would like to know in what way. Would you
tell me what foods you have eaten in the past twenty-four
hours?

Suppose we begin with your most recent meal.

FOOD AMOUNT COMMENT

 

 

395

Name: Subject Number:

 

 

FOOD AMOUNT COMMENT

 

 

 

396

Name: Subject Number:

 

1. Was this a usual day?

 

2. Are there any foods that you never eat? Why don't you
eat them?

 

 

 

3. Are there any foods that you used to eat that you don't
eat anymore? Why don't you eat them?

 

 

 

 

4. Are there any foods that you eat now that you didn't
eat before? Why did you begin to eat them?

 

 

 

5. Are there any foods that are difficult for you to eat?
Why?

 

 

6. Do you prepare your meals?

 

397

Name: Subject Number:

9.

10.

 

 

-4-

What do you think about when you choose foods for your
meals? Why did you have for dinner
yesterday?

 

 

 

 

Do you usually eat breakfast as soon as you get up in
the morning? Do you eat with someone at breakfast?
When do you usually eat again following breakfast? Do
you eat with someone? Continue through their daily
pattern.

 

 

 

 

 

How many meals do you eat with someone each week? With
whom do you eat?

 

 

 

How many meals do you eat alone each week?

 

 

 

 

 

 

398

Name: Subject Number:

 

-5-

11. How many meals per week do you usually eat outside
your home? With whom do you eat?

 

 

 

12. Which day or days of the week do you usually eat out?

 

 

13. Do you have prepared meals brought to you?

 

 

14. Do you shOp for your food?

 

 

15. Is there someone who helps you with your shopping?

 

16. How frequently do you ShOp for food?

 

 

17. At what store do you buy most of your food?

 

 

18. Is there a particular reason why you shop there?

 

 

399

Name: Subject Number:

 

 

_6_

19. Is this store within walking distance of your home?

 

 

20. Is any food brought into your home for you?

 

 

 

21. Do you have routemen who stop at your door to sell
food to you?

 

 

22. When you went ShOpping for groceries the last time,
what did you buy?

 

 

 

 

 

23. What facilities do you have for storing groceries?

 

 

24. Do you use any frozen foods? If so, what kinds of
foods?

 

 

 

Name 3

25.

26.

27.

28.

29.

30.

400

Subject Number:

 

 

-7-

What facilities do you have for storing frozen food?

 

Do you use any frozen prepared dinners like TV dinners?

 

 

 

Are there any particular times of the day or night
other than your regular mealtimes when you feel
especially hungry? What do you usually eat at those
times?

 

 

 

What kind of salt do you use, plain or iodized?

Do you do any work to supplement your income? What is
the nature of this work?

 

 

Do you receive any regular income other than Social
Security?

 

 

Name :

31.

32.

33.

34.

401

Subject Number:

 

 

_8_

If you were to receive an extra $100 per month, what
would you do with it? If spent for food, what kind of
food?

 

 

 

Do you feel that your choice of foods is limited by
financial considerations?

 

 

 

Are you on a diet? What led you to go on a diet?
What kind of diet is it?

 

 

 

 

Do you take vitamin supplements? If so, how long have
you been taking them? What led you to start taking
them? What kind are they? If not, have you taken them
at any previous time? What kind were they? Are you
taking any other supplements? If so, what kind?

 

 

 

 

Name :

35.

36.

37.

38.

39.

402

Subject Number:

 

 

-9—

Are you bothered with constipation? When you are, do
you take or eat anything special to relieve or prevent
it?

 

 

 

Are there any foods that you use or enjoy that you
must obtain at a Specialty store like an Italian
grocery store, or health food store, or delicatessen?

 

 

 

Do you have a garden and raise any of your own food?

 

 

 

Do you do any canning or preserving of food or make
jam?

 

 

Do you think your food habits have changed as you have
become older? How?

 

403

Name: Subject Number:

 

 

-10-

40. Does an older person need the same types of food
younger person?

as

 

 

 

ACTIVITIES CHECK LIST:

 

Church:

 

Organizations
Bridge Club:
Garden Club:
Woman's Club:
Senior Citizens:
Church-related Society:

Other: Specify:

 

 

 

 

Community Service
YWCA:
Red Cross Gray Ladies:
Other Volunteer Service: Specify:

 

Remarks:

 

 

 

How do you spend your day:

 

404

Name: Subject Number:

 

 

_11_

Do you have any children or other close relatives living
nearby? How frequently do you talk with them or see them?

 

 

 

RATING SCALE FOR SIGNS OF AGING

 

Hair:
Baldness NONE__ MODERATE___MARKED___COMPLETE__
Graying NONE__ MODERATE__ MARKED__ COMPLETE__
Teeth: Yellowing NONE__ MODERATE___MARKED__ COMPLETE__

Hearing: Deafness NONE___MODERATE__ MARKED__ COMPLETE__

Skin: Wrinkling SOME___MODERATE__ MARKED__ CHILDHOOD
SKIN__
Movement: AGILE__ MODERATELY SLOW__ STIFF__
NEEDS HELP__

Posture: Shoulders ERECT__ ROUNDED__ STOOPED__ MARKEDLY
STOOPED__

Remarks:

 

 

 

 

405

Appendix A-3

 

Schedule for Written Food Records
by Survey Subjects

NAME:
ADDRESS:

 

 

 

PHONE:

 

Please list on the following page all the foods that you
eat or drink during one particular day both at mealtime and
between meals as snacks. Try to indicate the amount of
each food in household measure, as the number of level or
heaping tablespoons, a cup of liquid, or one slice. You
might indicate how the food was prepared if baked, broiled,
fried, or heated in water or other liquid. You may wish to
record the foods immediately following your meal or snack
so that no items are overlooked.

I will return in a few days to collect your food record.
If you have any questions please feel free to call me,
Eleanor Schlenker, at 353-2937 or 355-3839. We greatly
appreciate your cooperation in this study.

406

NAME DATE:

 

FOOD AMOUNT HOW PREPARED

 

 

 

407

 

 

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VIC prcoCMC

APPENDIX B

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER III

ggpendix B-l

 

Certificate of Death
Michigan Department of Public Health

 

 

 

 

 

 

 

 

 

 

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DETACI'I INSTRUCTIONS IEFORE HUNG CRTIFICATE WITH REGISTRAR

TYPE OR PRINT (EXCEPT SIGNATURES) IN BLACK INK—THIS IS A PERMANENT RECORD

Michigan Public Act 343 of 1995, as amended, reaunes that the attending physician, or in the absence at on attending physiCIon, o
coroner shall Fill out and sign the medical certihcate a! death wrthin 94 hours alter death.

The Iuneml director is responsible for completing all other portions ol the certificate and obtaining a burial or removal permit prior
'0 dimming ol the body or removing from the registration district where the death occurred.

N\any important legal, personal, public health and social weltare interests require complete and accurate registration ol all deaths.
Individuals ".5 cortihcotion ot Ihc lacts ot death lar insurance claims, liauidot-on 0‘ estates. to prove none 0' mouse and parents and
other general legal use. Social and health agencies need information on the causes at death tor Dufootet ol Dlonnino health 0109")!“
"WY need In‘ormolton on the number of births and deaths in trialling population estimates,- and they need birth and death statistics to measure
the fertility and mortality at various ratial, economc or social groups.

408

APPENDIX B

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER III

409

Appendix B22

 

Age and Year of Death of Deceased Subjects

 

Subject Age in 1948 Age at Death
Number (years) (years) Year Of Death
101 72 83 1959
102 77 79 1951
103 56 64 1956
104 67 79 1960
105 76 79 1951
106 69 77 1957
107 40 41 1949
108 88 88 1949
109 71 74 1951
111 69 89 1969
112 67 86 1967
113 78 88 1959
114 69 88 1967
115 70 93 1972
116 66 73 1956
117 62 67 1954
118 84 87 1952
119 70 92 1970
120 60 65 1954
121 68 75 1955
122 48 68 1968
123 61 81 1968
124 62 79 1966
125 53 65 1960
126 61 73 1960
127 65 73 1957
128 62 68 1955
129 77 84 1956
130 54 77 1971
131 64 77 1961
132 82 91 1958
133 58 79 1970
134 73 84 1959
135 75 77 1951
136 63 82 1967
137 59 60 1950
138 71 82 1959
139 60 76 1965
141 65 79 1962
142 62 81 1967

143 73 87 1962

410

 

- _
..—~.

___
-_

 

Subject Age in 1948 Age at Death Year of Death
Number (years) (years)
145 81 87 1954
146 S6 66 1959
147 66 84 1966
148 62 85 1971
149 73 83 1959
150 75 81 1955
151 71 77 1955
152 60 76 1964
153 75 84 1958
154 74 78 1953
155 63 67 1952
156 77 88 1960
157 67 78 1960
159 58 74 1964
160 63 82 1968
161 56 79 1971
162 72 95 1971
163 55 78 1972
164 56 80 1972

 

411

 

mmmma HauOB

 

onm mm vmmma uouum

meo. Hue.m man N mmmm conmmummm
wocmua Hcma mumavm anmmum mmumavm
.m. .m m can: no mmmuoma mo Sam

 

mnma ou Hawum no cw beam 023 muomnnam mo
musmwmum boon aflaoumxm can mama CH mxnucH ucmfluusz mcfiumHmm coflumsvm cowuoflcmum

coflmmmummm How mommaum> mo mammamc<

 

Mim wacmmma

APPENDIX C

SUPPLEMENTARY DATA FOR CHAPTER IV

APPENDIX C

SUPPLEMENTARY DATA FOR CHAPTER IV

Appendix C-l

 

Age and Number of Food Records of Deceased
Subjects Secured in 1948

 

 

. A e Number of Food
Subject Number (yegrs) Records
101 72 1
102 77 2
103 56 3
104 67 3
105 76 1
106 69 1
107 40 3
108 88 1
109 71 2
111 69 2
112 67 4
113 78 1
114 69 2
115 70 2
116 66 3
117 62 1
118 84 1
119 70 3
120 60 3
121 68 3
122 48 1
123 61 3
124 62 1
125 S3 7

412

413

 

 

. A e Number of Food
Subject Number (years) Records
126 61 1
127 65 1
128 62 1
129 77 5
130 54 1
131 64 3
132 82 3
133 58 1
134 73 2
135 75 1
136 63 r\ l
137 59 5
138 71 1
139 60 1
141 65 1
142 62 1
143 73 2
145 81 3
146 56 3
147 66 3
148 62 l
149 73 3
150 75 1
151 71 1
152 60 1
153 75 3
154 74 1
155 63 3
156 77 3
157 67 l
159 58 3
160 63 2
161 56 l
162 72 4
163 55 1
164 56 2

 

414

Appendix C-2

 

Age and Number of Food Records of Survivors

_ —.——. --———_—.— _.__

 

 

 

Subject Age Number of Food Age Number of Food
Number (years) Records (years) Records

1948 1948 1972 1972
202 57 3 81 3
204 45 2 68 2
205 59 1 83 1
206 56 5 8O 2
207 43 1 66 3
208 50 2 73 1
209 57 1 81 2
212 52 4 75 1
213 51 l 75 5
214 56 1 81 3
215 52 2 75 3
216 66 3 90 l
218 46 1 69 3
220 60 1 85 1
221 40 2 64 3
223 48 l 71 1
224 45 2 68 3
225 53 2 77 2
226 61 2 85 8
228 40 2 64 1
230 50 1 73 1
232 52 1 75 2
233 43 2 67 3
235 45 l 69 2
239 50 1 74 2
241 52 1 75 3
242 45 1 69 3
244 56 9 80 1

 

APPENDIX D

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER V

APPENDIX D

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER V

Appendix D-l

 

Protocol for Clinical Testing
at Olin Health Center

NUTRITIONAL STATUS of; OLDER WOMEN

 

 

PROTOCOL

 

Subjects to be admitted to Olin Health Center the evening

prior to
8:00 P.M.

7:30 A.M.

8:30 A.M.

9:15 A.M.

testing.

Dental examination - Dr. Larry Stone D.D.S.

Subject will be awakened
A. Blood pressure measurement before
arising
* B. Fasting urine sample obtained
C. Fasting blood sample obtained

High carbohydrate breakfast (approximately 60
gm carbohydrate)

Clinical evaluation
A. Physical examination

1.
2.
3.

4.
5.

Vital functions - heart, lungs,
neurological reflexes

Blood pressure in standing
position

Deficiency symptoms - eyes, lips,
tongue, gums, skin

Medical history

Evaluation in relation to age

B. X-rays - chest, lower spine, wrist

C. EKG

415

416

10:30 A.M. Post-prandial urine sample obtained
Post-prandial blood sample obtained

11:15 A.M. Anthropometric measurements

A.
B.
C.

12:30 P.M. Lunch

Body weight

Body height - sitting, standing
Skeletal widths - bi-acromial, bi-iliac,
chest

Circumferences - upper arm, waist,
maximum hip, calf

Skinfold thicknesses - biceps, triceps,
subscapular, waist

Flexibility - shoulder rotation, ankle
flexion

Grip strength - right, left

Physical activity recall record

1:30 P.M. Return home

* Collection of all urine voided by subject between 7:30
A.M. and 10:30 A.M. Each voiding will be placed in a
separate bottle and labeled according to time of

collection.

 

 

 

01
PE

801

011

R E MA

417

Appendix D-2

 

Schedule Used for Oral Examination

Name: Subject Number:
Address: Phone:

 

 

 

 

ORAL EXAMINATION

 

Dentist: Date:

 

 

MISSING TEETH (encircled)
2 3 4 5 6 7 8 9 10 ll 12 13 14 15
31 30 29 28 27 26 25 24 23 22 21 20 19 18

Why Missing:

 

 

ORAL HYGIENE GOOD FAIR POOR
PERIODONTICS NONE SOME SEVERE

SOFT TISSUE PATHOLOGY:

 

 

 

 

 

 

 

 

 

PROSTHESIS
Maxilla
CD NONE___ HOW LONG
PD NONE___ HOW LONG
Bridge NONE___ HOW LONG
Mandible
CD NONE___ HOW LONG
PD NONE___ HOW LONG
Bridge NONE___ HOW LONG
DIETARY VARIETY ANYTHING LIMITED

SEVERELY LIMITED

REMARKS:

 

 

 

\i'llli‘lf. It?

RE!

LA

 

 

418

Appendix D-3

 

Schedule for Recording Urine Data

Name: Date:

 

NUTRITIONAL STATUS 93 OLDER WOMEN

 

 

DATA SHEET:

 

 

 

 

BLOOD PRESSURE (recumbent) TIME:
FASTING URINE COLLECTION
(7:30 A.M.)
VOLUME: m1 TIME:
COLOR: APPEARANCE (at time of
Pale yellow collection)
Dark yellow Clear
Reddish yellow Cloudy
Reddish brown Sediment
Brown
REMARKS: NURSE:

 

 

 

 

COLLECT ALL URINE VOIDED BY SUBJECT BETWEEN 7:30 A.M.
and 10:30 A.M. PLACE EACH VOIDING IN A SEPARATE BOTTLE AND
LABEL ACCORDING TO TIME OF COLLECTION.

VOLUME: ml TIME: NURSE:

 

 

 

VOLUME: ml TIME: NURSE:

 

 

 

VOLUME: ml TIME: NURSE:

 

 

 

419

POST-PRANDIAL URINE COLLECTION

VOLUME: ml

 

COLOR:
Pale yellow
Dark yellow
Reddish yellow
Reddish brown
Brown

REMARKS:

lllll

 

 

 

(10:30 A.M.)

TIME:

 

APPEARANCE (at time of
collection)
Clear
Cloudy
Sediment

 

\. III... III,

 

E!

 

420

Appendix D-4

 

Schedule Used for Physical Evaluation

 

 

 

 

 

 

 

 

 

 

Name: Age: Subject Number:
Address: Phone:

Family Member: Phone:

Address:

Physician: Phone:

Address:

 

 

PHYSICAL EVALUATION

 

 

 

 

 

 

 

Medical Examiner: Date:
GENERAL APPEARANCE POOR FAIR GOOD
EYES
Crusted Eyelids A P
Blepharitis O l 2 3
Palpebral Conjunctiva
Inflammation 0 1 2 3
Hypertrophy 0 l 2 3
Folliculosis 0 1 2 3

 

Bulbar Conjunctiva
Increased Vascularity
Thickening
Spots (number)

Circumcorneal Injection A

Outer Canthi Lesions O

Rotation A

 

OO
|._a
N

 

 

 

 

'Ut-I'U
N
w

 

Remarks:

 

 

 

KEY - Absent
Present
Scars

= Normal

, 2, 3 = Degree of Severity

PJOCDTJD
H

421

NAME: Subject Number:

 

SKIN - FACE
Complexion - Color

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Good
Pallor 0 l 2 3
Suborbital Pigmentation A___ P ‘—_—
Nasolabial Seborrhea o: l___ 2 3
Follicular Plugs 0___ l___ 2___ 3___
LIPS
Angular Stomatitis 0___ l___ 2 3
Cheilosis 0___ l___ 2 3
GUMS
Gingivitis 0___ l___ 2 3
Recession 0___ l___ 2 3
Retraction 0___ l___ 2 3
Remarks:
TONGUE
Red (color) 0___ l___ 2 3
Magenta (color) 0___ l___ 2 3
Papillae, Filliform
Atrophy 0___ l___ 2___ 3___
Hypertrophy A___ P___
Papillae, Fungiform
Atrophy 0___ l___ 2 3
Hypertrophy A___ P___
Swelling A___ P___
Fissuring 0___ l___ 2 3

NECK
Thyroid - Goiter 0 l 2 3

I
l

 

 

422

Name: Subject Number:

 

LYMPH NODES
Enlargement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anterior Cervical O l 2__. 3___
Posterior Cervical 0 l 2___ 3___
Supraclavicular 0 1 2___ 3___
Axillary 0 l 2___ 3___
Inguinal 0 l 2 3
EARS
Right NORMAL__ DISCHARGE__ WAX
0_1_2_3_
Left NORMAL__ DISCHARGE__ WAX
0_l_2_3_
NOSE
Discharge NONE MUCUS___ PUS___
Obstruction NONE: MUCUS__ PUS_____
Other Abnormalities EXPLAIN:
SKIN - GENERAL
Xerosis 0 l 2___ 3___
Folliculosis O l .___ 3___
Perifollicular Petechiae A P
Purpura A P
Dermatitis A P
Crackled Skin 0 l 2___ 3___
Creases 0 1 2___ 3___
Hyperkeratosis (elbows) 0 1 2___ 3___
Hyperkeratosis (knees) 0 1 2 3
Pigmentation 0 1 2::: 3::::
Other Lesions EXPLAIN:
LUNGS
Sounds
Rales A P
Wheezing A P
Breath Sounds
Vesicular A P
Bronchovesicular A P
Expansion 0 l 2 3

 

423

Name: Subject Number:

 

-4-

CARDIOVASCULAR SYSTEM
Heart Rhythm NORMAL___ OTHER
Sounds
Murmur

Functional
Organic
Abnormal Size

 

 

 

 

C>>IP
t—t’U'U

 

Pulse (standing position) TIME:

 

wszi>

3E2:

Blood Pressure (standing) TIME

 

Remarks:

 

 

 

GENERAL EDEMA 0 l 2 3

 

ABDOMEN
Hepatomegaly A P
Splenomegaly A
Other Masses on Organs
Bowel Sounds

 

 

 

 

LOWER EXTREMITIES
Paralysis
Joints

Enlargement
Pain
Muscle Cramps
Edema
Varicose Veins
Walking

’U

LOCATION

 

 

LOCATION
LOCATION
LOCATION
2___ 3___LOCATION___.
2___ 3
OTHER

 

 

 

 

 

 

 

 

2<Dc>>:>3’ b

E
hideaw'UNJ

 

Remarks:

 

 

SPINE
Kyphosis O l
Lordosis 0 l 2
Scoliosis 0 l

 

 

WWW

_—
.—
___

 

Name:

 

 

424
-5-

NEUROLOGICAL REFLEXES
Knee Jerk ABSENT

Biceps Jerk
Triceps Jerk
Ankle Jerk
Vibratory Sense
Proprioception
Babinski Reflex

EVALUATION IN RELATION
TO AGE
General Physical
Condition
Mental Competency

Psychological
Outlook

Alertness

Locomotion

Remarks:

Subject Number:

HYPOACTIVE

ABSENT:: HYPOACTIVE
ABSENT__ HYPOACTIVE
ABSENT__ HYPOACTIVE
ABSENT__ HYPOACTIVE
ABSENT__ HYPOACTIVE
ABSENT__ HYPOACTIVE

TYPICAL
APPEARS
TYPICAL
APPEARS

TYPICAL
APPEARS
TYPICAL
APPEARS
TYPICAL
APPEARS

FOR AGE___
YOUNGER___
FOR AGE

YOUNGER___

FOR AGE___
YOUNGER___
FOR AGE___
YOUNGER___
FOR AGE___
YOUNGER___

 

HYPERACTIVE__
HYPERACTIVE__
HYPERACTIVE__
HYPERACTIVE__
HYPERACTIVE__
HYPERACTIVE__
HYPERACTIVE__

APPEARS OLDER

APPEARS OLDER

APPEARS OLDER
APPEARS OLDER

APPEARS OLDER

 

 

 

 

425

Name: Subject Number:

 

 

-5-

MEDICAL HISTORY

 

Have you had any serious illnesses in recent years? If
so, what were they? How long was it before you could
resume your normal activities?

 

 

 

Have you had any surgery in recent years? If so, what
was involved? How long was it before you could resume
your normal activities?

 

 

 

Have you had any broken bones in recent years? If so,
what was broken? Did you regain full use of your limb?

 

 

Do you have any repeating pains? If so, where?

 

 

Do you lose your appetite for more than one day at a
time?

426

 

 

 

 

 

Name: Subject Number:
-7-
6. Do you tire easily?
7. Do you take medicines regularly? Were they prescribed

by a doctor? What are they for?

 

 

 

 

 

Remarks:

 

 

 

 

427

 

 

.mmma .omcowmo Hmcoflumz MOM cofluflupsz co mouuHEEOO HmucoEuummocuoucHn

Amcflumuomacoc .ucmcmoumcocv coEos panama
i HHe COH\mec

ov.o A mm.o om.o mH.o i oa.o OH.o v cflom canuoomm mammam
i i i HHe o0H\msc

ooa A mm ov mm i om compoumo mammam
I HHS OOH\msc

om A me ON mH i OH OH v 4 CHEEHH> mammHm
I Haemouma .>omc

me A we mm um i om om v ufluooumEom
i HHE OOH\smV

m.vH A v.va o.HH o.oa i 0.0H 0.0H v canoamoEom
i HHE OOH\emc

mm.v A vm.v mm.m Hm.m i om.~ om.~ v CHESQHm Esuom
i HHE OOH\smc

o.> A o.o m.o v.m i o.o o.o v cHouOHm Esuom Hmuoe

coax magnumooo< BOA unwaoawoa

manna coon mo coflumuoumuoucH on OUHDO coumommsm

 

min xHecmdma

428

.mme .omcomoo Hmcoflumz HON cofluwuusz co mouuHEEOU HmucoEuumaocuoucH

Q
Addaumuomasoc .ucmcmoumcocv cmEO3 pascam

 

Accecfiumouo Em\msv

 

osN M mmNiom mNiNN AN v cH>mHHonHm

l Hoaflcflummuo Em\msv
omH A mmaimm mminm hm v CHEMHCB
swam manmumooom 30H “COHOHmoo

 

n.omumo cofluouoxm CHEmuH> mumcfluo
mo coflumuoumuoucH Op OCHDO coummmmsm

 

o-o chammma

429

Appendix D—7

 

Serum Indices of Protein Metabolism in
Twenty Older Women Examined in 1972

 

Total

 

. Age Albumin . B.U.N.
subJeCt (yrs) g/100 ml 37203131 mg/100 ml
202 81 3.95 6.4 16
206 80 3.90 7.0 19
207 66 4.10 6.0 17
208 73 4.23 5.6 12
212 75 4.00 6.5 29
213 75 3.85 7.0 16
214 81 4.25 7.5 19
218 69 4.20 6.7 19
221 64 3.90 6.6 22
223 71 4.00 6.6 14
224 68 4.10 7.3 12
225 77 3.80 6.4 22
226 85 4.20 7.6 17
228 64 4.20 6.4 10
232 75 4.20 7.3 20
233 67 4.12 7.3 9
235 69 4.00 6.1 16
239 74 4.20 6.8 11
241 75 3.83 5.8 15
242 69 4.42 7.1 13

 

430

 

 

0.00 0.00 NO OOOO N0.0 N.mv 0.0H OO NON
0.00 0.0N OO OOHO O0.0 H.OO N.OH ON HON
O.NO 0.0N NO OONO O0.0 N.ov H.OH ON OON
n.NO 0.0N OO OOOO N0.0 N.OO 0.0H OO OON
0.0m 0.0N OO OOOO O0.0 H.HO N.OH NO NON
O.NO N.NO OO OOOO O0.0 0.00 0.0H ON NON
0.0m H.Om HOH OOOO OH.O N.NO 0.0H OO ONN
O.HO 0.0N NO OOHN H0.0 0.00 0.0H OO ONN
e.NO N.ON OO OOOO O0.0 e.ne 0.0H ON ONN
0.00 O.NO OO OOOO O0.0 H.OO 0.0H OO ONN
H.OO n.NO OO OOOO HN.O 0.00 0.0H HO ONN
H.OO 0.0N OO OOOO ON.O 0.00 0.0H OO HNN
N.OO 0.00 NO OOHO O0.0 0.00 0.0H OO OHN
0.0m 0.00 OO OONO OH.O 0.00 m.OH HO OHN
0.00 N.OO NO OOOO O0.0 0.00 0.0H ON OHN
0.0m N.NO OO OOOO O0.0 N.OO H.OH ON NHN
0.00 0.0N OO OOOO O0.0 n.NO 0.0H ON OON
0.00 0.00 NO OOOO N0.0 0.00 0.0H OO NON
0.0m O.HO OO OOOO H0.0 N.HO 0.0H OO OON
H.OO O.NO OO OOOO OH.O 0.00 0.0H HO NON
HOV HOssO H ac H see A sax OHV HO Ho>O HHE OOH\EOO HmHNO
omoz no: we: mmz O 0mm >OO cHnoHOosmm mO< Homnnsm

 

NOON CH COCHmem coEoz HOCHO
>uco3e Orv mo COOHm mcflummm mo mosam> onOHoumEom

 

O-6 xH666ONO

431

 

55.0 th me me New

 

OO.O HON OO ON HON
OO.H OON HO ON OON
OO.O OON OO OO OON
OO.O ONN NO NO OON
OO.O OOH OH v ON NON
OO.H OON OO «O ONN
NO.O OON NO NN ONN
OO.O OON NO OO ONN
ON.H OOH OO HN ONN
NO.O OOH NO OO HNN
OO.O OON NN OO OHN
OO.O ONH NO ON OHN
NO.O «O OO ON NHN
OO.O HNH OH ON OON
OH.H ONH OO OO NON
OO.O ONN OO OO OON
OO.H ONN OH HO NON

HHe OOH\O2O HHa OOH\OsO 1H8 OOH\OOO HOHNO uomOnsO
cHo< UHQHoomfi acouounu m d CHEmuH> mod .

 

thH CH UOCHEMXM C0503 HOUHO MO mHO>01H CHEMHHNV EDHOW

 

Oio chcmmmd

432

Appendix D-lO

 

Creatinine Ratios of Fasting Urine of Twenty
Older Women Examined in 1972

-—

 

. A e u Thiamin/ u Riboflavin/
SUbJeCt (ygs) gmgCreatinine g: Creatinine
202 81 3726 739
206 80 571 128
207 66 2035 1047
208 73 2168 1297
212 75 495 206
213 75 257 318
214 81 1220 301
218 69 121 37
221 64 168 179
223 71 688 154
224 68 203 584
225 77 243 43
226 85 2586 638
228 64 414 119
232 75 119 282
233 67 220 50
235 69 335 154
239 74 1059 307
241 75 663 97
242 69 297 121

 

Urine values expressed per unit volume are shown in
Appendix D-ll.

433

 

 

OOO.o OOH.o Nm.m NH.H OOm.o OO NON
OOo.o ONN.o Hm.m NO.N NH0.0 ON HON
ONH.o ON0.0 NH.O Nm.H OO0.0 ON ONN
ON0.0 OOH.O Nm.O NN.O NOO.o OO ONN
Omo.o OOH.o O0.0 NO.H ONN.o NO NNN
NmN.O OO0.0 N0.0 mo.O mNO.o mN NON
OOo.o mmH.o Ho.m OO.H ONm.o OO ONN
OHm.o OON.H O0.0 Nm.N mOO.o mm ONN
ON0.0 OOH.o OO.N Oo.m OmO.o NN mNN
OO0.0 ONN.o O0.0 OO.m HNH.H OO ONN
OO0.0 ONH.o NH.O OO.H OON.o HN ONN
OO0.0 OOO.o O0.0 NO.m omm.o OO HNN
OO0.0 OOH.O ON.OH NH.O OON.H OO OHN
NHH.O OmO.o O0.0 OO.N NNm.o HO OHN
OOH.O ONH.o O0.0 No.O HO0.0 mN NHN
OO0.0 OOo.o mN.N NN.N OOH.O ON NHN
NNN.O OON.H OO.N OO.N mOm.o ON OON
ONN.o OOO.H mm.N Hm.O HO0.0 OO NON
OO0.0 OHN.O O0.0 NO.N mNm.o om OON
OON.o HOO.H O0.0 O0.0 OOm.o HO NON
HHe\O=O HHE\OOO HHeerO HHeerO HHexmeO HmuNO uomOnsO
CH>mHmonHm CHEchB comouqu Hmuoe 2 won: OCHcHunouu- mod .

 

NNOH :H cocHmem c0203 HocHo
mucosa mo OCHHD mcHummm mo moon> HOOHEosoon

 

HHiO xHocmOOO

1H8 OOH\cHnoHOoEOH O: OO. Ac nooHn uHsooo i momuu
1H8 OOH\Oe OO :Hmuonm i 6688»

 

434

 

O>Hummmz i Hiv "ammo mHOOENO
iii iii iii iii OOO.H 0.0 30HHON OO NON
iii iii iii iii NOO.H 0.0 3OHHmw ON HON
iii iii iii iii NOO.H o.o 3OHHOM ON OON
iii iii iii iii OHO.H O.N 3OHHON OO OON
iii iii iii iii OOO.H 0.0 30HHOO NO OON
iii iii iii iii OHO.H 0.0 30HHOM ON NON
Iii iii iit iii OOO.H o.m 3OHHON Om ONN
iii iii iii iii HHo.H o.O BOHHOH OO ONN
iii iii iii iii NHO.H O.O onHmw NN ONN
OUMHfl III III OUMHfi OHO.H Oom 3OHHOW mm QNN
iii iii iii iii OOO.H 0.0 soHHmw HN ONN
momma iii iii iii OHO.H o.O 3OHHmw OO HNN
iii iii iii iii HOo.H o.O 30HHOO OO OHN
iii iii iii iii HHo.H o.N 3OHHON HO OHN
iii iii iii iii OOO.H O.O onHmN ON OHN
iii iii iii iii OOO.H 0.0 3muum ON NHN
iii iii iii iii OOO.H 0.0 onHow ON OON
iii iii iii iii OOO.H 0.0 soHHmw OO NON
iii iii iii iii OHO.H 0.0 soHHow OO OON
iii iii iii iii NOO.H 0.0 onHOw HO NON
COOHm uHsooo OOCOHOO Hmmsm CHOHOHO .w.m mm HOHOO O04 uomnnsm

 

NNOH OH :meoz HmOHO Oo mcHHO OOHHOOO Ho OOUHOOH

 

NHiO xHOcmOOO

435

Appendix D-13

 

Definitions of Clinical Symptoms

Eyes

Bitot's spots: Small circumscribed, grayish or yellowish-
gray, dull, dry, foamy superficial lesions of the
conjunctivae.

Blepharitis: Inflammation of eyelids.

Circumcorneal injection (bilateral): Increase in vas-
cularity by new ingrowth of capillary loops, with
particular concentration around the cornea in the
absence of obvious infection.

Conjunctival injection (bilateral): Generalized increase
in the vascularity of the bulbar conjunctivae in
the absence of obvious infection.

Thickened bulbar conjunctivae: All degrees of thickening
may occur. The blueness of the sclera may disappear
and the bulbar conjunctivae develop a wrinkled
appearance with increase in vascularity. The
thickened conjunctivae may result in a glazed,
porcelain-like appearance, obscuring the vascularity.

Skin

Crackled skin: Definite scales larger in size than those
seen in xerosis. It is not of nutritional origin.

Follicular hyperkeratosis: The skin is rough, with
papillae formed by keratotic plugs which project
from the hair follicles. The surrounding skin is
dry and lacks the usual amount of moisture or
oiliness. Lesion has been likened to "gooseflesh"
which is seen on chilling, but is not generalized
and does not disappear with brisk rubbing of the
skin.

Nasolabial seborrhea: A definite greasy yellowish
scaling or filliform excrescences in the nasolabial
area which become more pronounced on slight
scratching.

Pigmentation: Areas of darkened, brown pigmentation

(over the malar eminences, forehead, hands, or else-
where .

436

Purpura: Small localized extravasations of blood, red
or purplish in color, depending on time elapsed
since formation.

Xerosis: Dry and crinkled skin which is accentuated by
pushing the skin parallel to its surface. Nutri-
tional significance is not established.

Lips

Angular lesions: May appear as pink or moist white
macerated angular lesions which blur the muco-
cutaneous junction.

Angular scars: Scars at the angles, which, if recent,
may be pink; if old, may appear blanched.

Cheilosis: The lips are swollen or puffy and appear
as if the buccal mucosa extends out onto the lip.
There may be desquamation.

Tongue

Filliform papillae atrOphy: Filliform papillae are
exceedingly low or absent, giving the tongue a
smooth or "slick" appearance which remains after
scraping slightly with an applicator stick.

Fissures: Linear lesions or cracks, with a definite
break in continuity of epithelium.

Fungiform papillae atrophy: Positive finding if the
fungiform papillae cannot be readily seen.

Magenta colored: The color of alkaline phenolphthalein.
Papillae hypertrophy: Can be seen and is felt when a
tongue blade is drawn lightly over the anterior

two-thirds of the tongue.

Red (glossitis): Entire tongue is red, angry in
appearance, with or without denudation or fissures.

Note: Taken from the Interdepartmental Committee on Nutrition
for National Defense, 1963.

 

437

Appendix D-l4

 

Letter Requesting Authorization to Release
Medical Records to Personal Physician

We would like to take this Opportunity to thank you for
participating in our health and nutrition survey. As we
mentioned last fall, copies of your medical records per-
taining to the physical examination by Dr. Feurig, X-rays,
EKG, and blood and urine analyses, will be sent to the
physician whom you indicated. Inasmuch as all medical
records are regarded as privileged information, the Michigan
State University Health Center must receive written per-
mission from you authorizing them to release these records
to your physician.

I have enclosed an authorization form as well as a stamped,
self-addressed envelope. As soon as you return your
signed authorization to me, I will mail the set of records
to the physician you have chosen. If you have any ques-
tions, please do not hesitate to call me at 353-2937 or
355-3839.

We greatly appreciate your cooperation in making this
project a success.

Sincerely yours,

Eleanor D. Schlenker
Graduate Assistant

ES/em

Enclosures

438

Appendix D-15

 

Authorization Form for Release of Medical
Records to Personal Physician

MICHIGAN STATE UNIVERSITY
HEALTH CENTER

AUTHORIZATION FOR RELEASE OF INFORMATION

DATE

 

This is authorization for you to convey to

 

 

 

all information from my health records at Michigan State
University Health Center.

Signed

 

Address

 

 

APPENDIX E

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER VI

APPENDIX E

INSTRUMENTS AND SUPPLEMENTARY DATA

FOR CHAPTER VI

Appendix E—l

 

Schedule for Recording Anthropometric
Measurements

NAME DATE

 

 

NUTRITIONAL STATUS pg OLDER WOMEN

 

 

ANTHROPOMETRIC MEASUREMENTS

 

 

 

DATE OF BIRTH (day, month, year)
BODY HEIGHT BODY WEIGHT lbs.
Sitting cm
Standing cm
CIRCUMFERENCES SKELETAL WIDTHS
Upper arm cm Bi-acromial cm
.Minimum waist cm Bi-iliac cm
Inspiration cm
Expiration cm Chest cm
Maximum hip cm
Calf cm

439

440

SKINFOLD THICKNESSES

Biceps
Triceps
Subscapular

Waist

FLEXIBILITY
Shoulder

Ankle

EXAMINER

CIR
CIR
CIR

cm

degrees

degrees

 

CITI
cm
CHI

CIR

GRIP STRENGTH
Right

Left

lbs.

lbs.

CID

CITI

CID

CHI

 

 

441

Appendix E—2

 

Composition of High Carbohydrate Breakfast

High Carbohydrate Breakfast
(SO-60 grams carbohydrate)

 

Orange juice — 4 ounces

French toast -
1 1/2 slices enriched bread
12 grams CHO per slice
1 gram fat per slice

Table syrup -
2 tablespoons
15 grams CHO per tablespoon

Coffee or Tea

Sugar (optional) -
4 grams CHO per teaspoon

Cream substitute (optional) -
1.8 grams CHO per teaspoon
0.8 grams fat per teaspoon

Carbohydrate (g)

 

13.5

18.0

30.0

Fat (g)

442

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