Abstract
Objectives
Health-related quality of life (HRQoL) is a multidimensional health measurement and a key to optimal aging. The aim of this study was to examine the association of nutritional status with HRQoL in the elderly.
Design
Cross-sectional study.
Setting
Villanueva Older Health Study, a community-based study in Villanueva de la Cañada (Madrid, Spain).
Participants
83 (53 women) non-institutionalized inhabitants aged 80 years and above.
Measurement
HRQoL was assessed by EuroQoL-5D (EQ-5D) questionnaire, nutritional risk by Mini Nutritional Assessment (MNA) questionnaire and dietary intake by 24-hour dietary recall. Statistical significance was evaluated at 95% confidence level (P< 0.05).
Results
EQ-5D pointed out differences between men and women (0.782±0.235 and 0.633±0.247; p=0.02). Problems in mobility (total sample) and pain/discomfort (women) dimensions were most frequently reported. MNA (26.5±3.2 men and 24.3±3.2 women; p=0.03) revealed malnutrition in 3.3% of men and 1.9% of women, and risk of malnutrition in 6.7% and 37.7%, respectively. Total sample was at risk of folic acid, zinc, magnesium, vitamin D and vitamin E deficiency. EQ-5D was associated with MNA (p<0.001). EQ-5Dindex was associated with energy intake (p=0.04) and EQ-5Dvas was negatively correlated with body mass index (p=0.02). EQ-5D pain/discomfort dimension was associated with energy (p=0.006), protein (p=0.005), lipid (p=0.03), magnesium (p=0.032), phosphorus (p=0.012), selenium (p=0.043) and niacin (p=0.004) intake.
Conclusions
Women showed poorer HRQoL and higher malnutrition risk. A relationship between HRQoL and risk of malnutrition was observed. Results suggest that when energy and protein, lipid, phosphorus, magnesium, selenium and niacin intake increase, HRQoL is promoted, although the increase does not seem to have a strong direct effect on it. The limited influence of energy and nutrient intake on HRQoL observed requires further research.
Key words: Health-related quality of life (HRQoL), EuroQol-5D (EQ-5D), Mini Nutritional Assessment (MNA), dietary intake, non-institutionalized elderly
Introduction
In the European Union, people aged 80 years and above will be the fastest growing segment of the older population in the coming decades, with an important projected growth from 23.7 million (5%) in 2010 to 62.4 million (12%) in 2060 (1). Healthy aging is one of the challenges for developed countries because, while the number of years of life is important, the quality of life is even more so. Recently, health-related quality of life (HRQoL), rather than mortality or morbidity, has emerged as the key goal for health promotion in the elderly (2). HRQoL measures self-perceived health and includes the physical, functional, social and emotional well-being of an individual. A low HRQoL in very elderly people reflects the existence of hidden health problems related to disability or dependence and to malnutrition risk that need to be studied and prevented, and are susceptible to improvement (3).
Aging, affected by chronic conditions and barriers to health, is associated with an increasing deterioration in perceived health status (4), and the health status of the elderly is conditioned by several factors among which nutrition plays an important role. However, the relationship between quality of life and nutritional status has not been extensively studied (2, 5, 6, 7). The association between Mini Nutritional Assessment (MNA) and HRQoL has been studied previously (5, 7, 8, 9), but studies of the relationship between HRQoL and energy and nutrient intake are lacking.
The aim of the present study was to examine the association of nutritional status with HRQoL in non-institutionalized individuals aged 80 years and above living in a small Spanish town.
Materials and methods
A cross-sectional survey-Villanueva Older Health Study-was carried out, in 2011, in very old women and men living in Villanueva de la Cañada (16,804 registered inhabitants), Madrid (Spain). All non-institutionalized inhabitants aged 80 years and above (264) were invited by letter to participate and 98 persons composed the final study sample. There were no significant differences in age or gender between participants and non-participants. Data was collected by interview from February 2011 to June 2011 using comprehensive geriatric and nutritional assessment tools. Interviews were carried out by two geriatricians and one nutritionist at the primary health care centre or at subjects’ homes when transfer of the subject to the centre was impossible. Dementia was detected by neuropsychological study using the Mini Mental State Examination (MMSE), Clock test, MIS-Buschke and Photo test. The caregiver or a relative was interviewed only if the subject was cognitively impaired. In all cases, written informed consent was obtained from the subject or cohabiting next of kin. When assessing HRQoL, we stressed that the responses had to relate to how the patient was feeling on that day, rather than in general. Cognitively impaired individuals were excluded from the study of HRQoL because their responses to the EQ-5D questionnaire are considered unreliable (10), as the EQ-5D questionnaire measures self-perception. After exclusion (9) due to cognitive impairment, 6 due to lack of response to the EQ-5D or to the visual analogue scale [EQ-VAS]), 83 subjects underwent the final analyses. The study was conducted under a cooperative agreement between the Complutense University of Madrid and the Villanueva de la Canada City Council. It was done according to the guidelines laid down in the Declaration of Helsinki and all procedures were approved by the Research Committee of the Faculty of Pharmacy (Complutense University of Madrid).
Health-related quality of life assessment
The EuroQol EQ-5D is a standardised non-disease-specific instrument for describing and valuing health-related quality of life. It was developed in several countries, used in many age groups and it has been available since 1990 (11). The EuroQol-5D consists of two parts: the EQ-5D descriptive system and the EQ-VAS (12, 13, 14). EQ-5D describes health status in terms of five dimensions: mobility, self-care, usual activity, pain or discomfort, and anxiety or depression. Each of these dimensions is divided into three levels of severity (no problems, some problems and extreme problems). These data are then converted to a single overall score (EQ-5Dindex) using a predefined table of values (14). The score on the EQ-VAS ranges from 0-100. Zero represents the worst imaginable health state and 100 the best imaginable health state.
Dietary assessment
The evaluation of nutritional patterns of the elderly was conducted using 24-hour dietary recall, in which an investigator asks the respondent to enumerate the foods and beverages consumed in the preceding full day. Consumed quantities were estimated in units (e.g. fruits), servings and home-made measurements standardised for this study (15). Consumption data were classified using the Spanish Food Composition Tables of Moreiras et al. (15), and energy and nutrient content were subsequently calculated using the same database (15). Intakes were compared to Spanish recommended intakes (RI) (15) to judge the adequacy of the diet.
The Mini Nutritional Assessment (MNA)
The MNA is a clinical tool that can be used to identify geriatric subjects at risk for malnutrition (17-23.5 points) and malnourished (<17 points). Subjects scoring >24 points are well nourished. The MNA includes 1 8 items involving anthropometrical, dietary and subjective measurements. The MNA is well validated and correlates highly with clinical assessment and objective indicators of nutritional status (body mass index [BMI], energy intake and vitamin intake). MNA scores demonstrated both high sensitivity (98%) and high specificity (96%) (16).
Data analyses
All data were analysed using SPSS 19.0. A descriptive statistical analysis was carried out. The results were expressed as mean and standard deviation for continuous variables and as percentages for categorical variables. Statistical significance was assessed, as appropriate, with Student's t test or the Mann-Whitney U test. The Wilcoxon rank-sum test was also used as a nonparametric alternative to the two-sample test. Correlation study of the variables was performed using Pearson's r for normal distributions and Spearman's rho for non-parametric analysis. Dietary variables (energy and nutrient intake, and adequacy in terms of RI) were correlated against EQ-5Dindex, EQ-5Dvas and the five EQ-5D dimensions. In addition, the MNA results were correlated against those HRQoL variables. The level of significance used was 5%.
Results
Thirty men and 53 women (63.9%) aged 80 and above, all non-institutionalised, were included in the study (Table 1). The mean age was 86 years, 61% of the elderly were widowed (77.4% of the women) and 20.5% were living alone (24.5% of the women).
Table 1.
Characteristics of the sample
| All subjects | Men | Women | |
|---|---|---|---|
| N | 83 | 30 | 53 |
| Age (years), mean (SD) | 86.0 (4.7) | 84.5 (3.6) | 86.9* (5.0) |
| Without studies, % | 3.6 | 3.3 | 3.8 |
| Secondary school education (> 12 years), % | 22.9 | 36.7 | 15.1 |
| Widowed, % | 61.0 | 31.0 | 77.4* |
| Married, % | 34.1 | 69.0 | 15.1* |
| Living alone, % | 20.5 | 13.3 | 24.5 |
| BMIa(kg/m2), mean (SD) | 27.5 (4.9) | 27.6 (3.9) | 27.4 (5.5) |
| MNA, mean (SD) | 25.1 (3.3) | 26.5 (3.2) | 24.3* (3.2) |
| EQ-5D index, mean (SD) | 0.687 (0.250) | 0.782 (0.235) | 0.633* (0.274) |
| EQ-5D vas, mean (SD) | 65.02 (18.3) | 67.9 (17.3) | 63.4 (18.8) |
| No problems involving any of the five dimensions, % |
20.5 |
36.7 |
11.3 |
p< 0.05. Comparisons were estimated using the two-sample t-test or chi-square test
BMI All subjects, n=74; men, n= 29; women, n= 45;
HRQoL was poorer in women than in men when assessed by the EQ-5Dindex and EQ-5Dvas (Table 1). EQ-5Dindex showed differences between men and women (0.782±0.235 and 0.633±0.247; p=0.020). Only 11.3% of women against 36.7% of men had no problems relative to any of the five dimensions (Table 1). Figure 1 shows the proportion of participants reporting problems in the EQ-5D dimensions. Problems in mobility (total sample) and pain/discomfort (women) dimensions were those most frequently reported. Women had more problems involving all the dimensions. Self-care problems were those least reported in both sexes, as was the case of pain/discomfort in men. The pain/discomfort dimension differed between men (43.4%) and women (16.7%; p<0.001).
Figure 1.
The proportion of individuals reporting problems in the EQ-5D descriptive system
Table 2 shows the MNA results. Overall, 26.5% of the participants were found to be at risk for malnutrition and 2.4% were considered malnourished. Significant differences (p=0.030) were seen in nutritional status, as measured by the MNA, when men and women were compared (Table 1). In all, 37.7% of women were at risk for malnutrition, compared to 6.7% of men. Dietary assessment (Table 3) showed that the average intake of magnesium, zinc, folic acid, vitamin D and vitamin E did not reach 80% of RI. Dietary variables (energy and nutrient intakes, and adequacy in terms of RI) were correlated against EQ-5Dindex, EQ-5Dvas and the five EQ-5D dimensions. In addition, the MNA results were correlated against those HRQoL variables. Pearson's correlation coefficients for the analysis of the EQ-5D scores in terms of BMI, MNA and energy intake are shown in Table 4. Relatively weak but highly significant correlation was found between MNA and EQ-5D scores (EQ-5Dindex and EQ-5Dvas). EQ-5Dindex was associated with energy intake (p=0.04) and EQ-5Dvas was negatively correlated with BMI (p=0.02). EQ-5D pain/discomfort dimension was negatively associated with energy (p=0.006), protein (p=0.005), lipid (p=0. 030), magnesium (p=0.032), phosphorus (p=0.01 2), selenium (p=0.043) and niacin (p=0.004) intake (Table 3).
Table 2.
MNA results
| MNA (n) | All subjects (83) | Men (30) | Women (53) |
|---|---|---|---|
| Normal nutritional status (>23.5), % | 71.1 | 90.0 | 60.4 |
| At risk of malnutrition (17-23.5), % | 26.5 | 6.7 | 37.7 |
| Malnourished (<17), % |
2.4 |
3.3 |
1.9 |
Table 3.
Energy and nutrient intakes, adequacy in terms of RI and Spearman's correlation coefficients between EQ-5D pain/discomfort dimension and energy and nutrient intakes
| Men Intake Mean (SD) | Men Adecuacy to RI (%) Mean (SD) | Women Intake Mean (SD) | Women Adecuacy to RI (%) Mean (SD) | Intake Mean (SD) | Adecuacy to RI (%) Mean (SD) | Pain/Discomfort EQ-5D | ||
|---|---|---|---|---|---|---|---|---|
| Energy ** (Kcal) | 1661.9 (406.9) | 73.0 (18.9) | 1463.7 (325.4) | 75.8 (18.4) | 1535.4 (367.3) | 74.8 (18.5) | rs
|
-0.299
|
| Proteins** (g) | 66.6 (18.9) | 127.0 (37.5) | 63.0 (18.3) | 153.1 (44.9)b | 64.3 (18.5) | 143.6 (44.0) | rs -
|
0.303
|
| Lipids* (g) | 63.8 (26.2) | 57.3 (21.5) | 59.7 (23.4) | rs
|
-0.238
|
|||
| Carbohydrates (g) | 190.3 (53.7) | 170.3 (47.8) | 177.5 (50.6) | rs
|
||||
| Fiber (g) | 17.9 (7.6) | 14.5 (7.2)” | 15.7 (7.5) | rs
|
-0.094
|
|||
| Calcium (mg) | 9.18 (318.4) | 14.8 (39.8) | 759.6 (275.7) | 94,9 (34.5) | 817.2 (300.0) | 102.1 (37.5) | rs
|
-0.143
|
| Iron (mg) | 10.8 (3.0) | 108.1 (29.8) | 9.3 (3.2)” | 92.8 (32.3)” | 9.8 (3.2) | 98.4 (32.1) | rs
|
-0.121
|
| Magnesium* (mg) | 267.3 (86.0) | 77.5 (24.6) | 216.0 (57.2)b | 71.8 (19.1) | 234.5 (72.8) | 73.8 (21.3) | rs
|
-0.235
|
| Zinc (mg) | 7.3 (2.1) | 48.4 (13.9) | 7.2 (3.7) | 47.5 (25.0) | 7.2 (3.2) | 48.0 (21.5) | rs
|
-0.137
|
| Phosphorus* (mg) | 1257.0 (336.3) | 179.6 (48.0) | 1061.7 (263.8)” | 151.7 (37.7)” | 1132.3 (305.0) | 161.8 (43.6) | rs
|
-0.273
|
| Selenium* (№) | 76.5 (29.5) | 111.3 (41.3) | 62.3 (35.8)” | 112.5 (64.4) | 67.4 (34.1) | 112. 1 (56.8) | rs
|
-0.222
|
| Vitamin B1 (mg) | 1.0 (0.2) | 103.2 (27.1) | 0.9 (0.4)” | 116.8 (53.9) | 1.0 (0.4) | 111.9 (46.3) | rs
|
-0.017
|
| Vitamin B2 (mg) | 1.5 (0,5) | 110.5 (37.2) | 1.5 (0.8) | 134.3 (72.1) | 1.5 (0.7) | 125.7 (62.6) | rs
|
-0.024
|
| Niacin** (mg) | 24.4 (7.6) | 156.9 (50.1) | 22.6 (6.4) | 187.7 (54.1)” | 23.2 (6.9) | 176.5 (54.5) | rs
|
-0.311
|
| Vitamin B6 (mg) | 1.5 (0.5) | 85.0 (30.4) | 1.4 (0.5) | 88.7 (31.5) | 1.5 (0.5) | 87.3 (31.0) | rs
|
0.064
|
| Folic acid (№) | 218.1 (104.7) | 54.5 (26.2) | 197.0 (93.6) | 49.2 (23.4) | 204.6 (97.7) | 51.1 (24.4) | rs
|
-0.064
|
| Vitamin B12 (№) | 4.3 (2.6) | 213.3 (132.3) | 6.4 (13.4) | 318.8 (669.6) | 5.6 (10.8) | 280.7 (541.4) | rs
|
0.099
|
| Vitamin C (mg) | 136.5 (69.2) | 227.5 (115.4) | 134.5 (65.9) | 224.1 (109.8) | 135.2 (66.7) | 225.3 (111.1) | rs
|
-0.139
|
| Vitamin A (№) | 738.3 (775.5) | 76.3 (81.4) | 961.1 (2376.6) | 120.0 (297.1) | 880.5 (1950.9) | 104.22 (242.42) | rs
|
-0.170
|
| Vitamin D (№) | 2.4 (4.1) | 16.0 (27.2) | 3.3 (6.2) | 22.0 (41.4) | 3.0 (5.5) | 19,82(36.8) | rs
|
0.029
|
| Vitamin E (mg) |
4.8 (3.2) |
39.8 (26.7) |
5.4 (4.7) |
44.9 (39.0) |
5.2 (4.2) |
43.0 (35.0) |
rs
|
-0.034
|
* p< 0.01, * p<0.05; Spearman's Correlation. b p<0.01, a p<0.05; comparisons were estimated using the Mann-Whitney.
Table 4.
Pearson's correlation coefficients for EQ-5D scores with nutritional variables (BMI, MNA, energy intake)
| EQ-5D index | EQ-5D vas | ||
|---|---|---|---|
| BMI* | r | -0.20 | -0.25 |
| Sig. (2-sided) | 0.07 | 0.02 | |
| MNA** | r | 0.57 | 0.34 |
| Sig. (2-sided) | 0.00 | 0.00 | |
| Energy intake* | r | 0.31 | 0.15 |
| Sig. (2-sided) |
0.04 |
0.17 |
* p< 0.01, * p<0.05
Discussion
In the present study, we assessed HRQoL (EQ-5D), nutritional status (MNA and dietary assessment) and the possible relationship between them in non-institutionalized individuals aged 80 years and above living in a small Spanish town.
HRQoL was poorer in women than in men, as shown by other studies 5, 17, 19, and EQ-5Dindex revealed significant differences between men and women. Women had more problems in all the dimensions and only 11.3% of them reported no problems involving any of the five dimensions of the EQ-5D. Problems in the mobility (total sample) and pain/discomfort (women) dimensions were those most frequently reported. Self-care problems were those least reported in both sexes, as were pain/discomfort problems in men. These results do not agree with The European Study of the Epidemiology of Mental Disorders (ESEMeD), which included the study of HRQoL and was conducted in six European countries (17). In that study, problems involving the pain/discomfort dimension were those most frequently reported and problems relative to the anxiety/depression dimension were the least frequent. These discrepancies with our study could be due to a smaller number of participants and to differences in age and gender distribution of the participants. The European study pointed out that respondents from Spain tended to report problems in the pain/discomfort dimension significantly less frequently than the grand mean (17). Another Spanish study (18), which takes into account elderly people from the same region, also showed the pain/discomfort dimension to be the most frequently reported but, in this case, it agrees with our study in that the least reported was the self-care dimension. The EQ-5Dvas score in our study (65.02) was higher than in the European study (17): 63.8 for the Spanish participants (>75 years) and 62.03 for the total elderly people (>80 years). On the other hand, our score was lower compared to the value obtained in the Madrid study (66.6) but, in this study, we should point out that the sample included younger people above 65 years (18). In general, our study reports greater numbers of elderly individuals with problems involving any of the EQ-5D dimensions than other studies 17, 18 but the EQ-5Dvas score appears to be higher. The cause for this controversy could be that EQ-5D dimensions show whether a person has any difficulty, whereas the EQ-5Dvas reflects the overall perception of health status. Elderly people with serious disabilities could consider that their general health is not so poor, thus reflecting their adaptation to their deficiency.
Our study found significant differences in MNA results when comparing men and women (26.5±3.2 men vs 24.3±3.2 women; p=0.03). Some studies obtained significant gender differences (5) for MNA results, while others did not (8). MNA revealed malnutrition in 3.3% of men and 1.9% of women, and risk of malnutrition in 6.7% and 37.7%, respectively. One of the reasons why more women are at risk of malnutrition could be that a higher proportion of women live alone. The proportion of the total participants that were at risk for malnutrition (26.5%) or were malnourished (2.4%) was similar to the data shown in Guidoz's review (24% at risk and 2% malnourished) (16). Dietary assessment showed an adequate intake of calcium, iron, selenium, vitamin B1, vitamin B2, vitamin B6 and vitamin A. Overall, the sample exceeded RI for protein, phosphorus, niacin, vitamin B12 and vitamin C, and was at risk of magnesium, zinc, folic acid, vitamin D and vitamin E deficiency. These results are similar to those obtained in the Spanish participants (aged 75-78 years) in the Euronut-SENECA Study (20).
Regarding the relationship between nutritional status and HRQoL, the evidence in the literature is mixed due to the different approaches employed to evaluate the nutritional status. In our report, the correlation study of MNA results and dietary variables (energy and nutrient intakes, and adequacy in terms of RI) against EQ-5Dindex, EQ-5Dvas and the five EQ-5D dimensions led to brand-new findings. Relatively weak but highly significant correlation was found between MNA and EQ-5D scores (EQ-5Dindex and EQ-5Dvas). Previous studies indicated that significant association exists between the risk of malnutrition and reduced HRQoL (5, 9, 21, 22, 23). In a group of hospitalised elderly patients, nutritional status did not appear to directly influence quality of life but, in that study, BMI, mid-arm muscle circumference, presence of appetite and swallowing problems were used as nutritional variables (6).
EQ-5Dvas was negatively correlated with BMI (p=0.02). The association between BMI and HRQoL was investigated previously in other studies (5, 24, 25, 26), which found impaired HRQoL in both obese and underweight individuals. There are also studies in which no correlation between BMI and HRQoL was observed (6).
This is the first report of the possible associations between energy and nutrient intakes, on one hand and HRQoL on the other, and this could stimulate more research aimed at improving quality of aging.
EQ-5Dindex was associated with energy intake (p=0.04), and the EQ-5D pain/discomfort dimension was negatively correlated with energy and certain nutrient intakes. In other studies, the pain/discomfort dimension was also found to be of importance for nutritional status 8, 27. We observed that when energy, protein, lipid, magnesium, phosphorus, selenium and niacin intakes increase, the EQ-5D score for the pain/discomfort dimension decreases. Dependence is not high and, thus, this significant correlation requires further investigation.
The small sample size (only 83 of 264 inhabitants) and the small number of men, a common situation when studying an older population, should be considered limitations of the study (28). Inhabitants were not excluded but they did not want to participate in the study. Another issue to be taken into account is the fact that the sample consists solely of non-institutionalized elderly people. Cross-sectional community-based studies of health status are subject to under-representation of elderly individuals placed in long-term care institutions. Neither should be forgotten the limitations consequence of the use of the 24h recall as the method chosen for the dietary assessment (29), but for this study in which very old people underwent many tests in the same appointment this method was considered as the more suitable due to its simplicity and its relatively little burden on the respondents.
In conclusion, women have a poorer perception of their HRQoL and are found to be more at risk of malnutrition. Risk of malnutrition and energy intake are associated with quality of life in elderly people. Energy, protein, lipid, magnesium, phosphorus, selenium and niacin intakes seem to be more closely related to the EQ-5D pain/discomfort dimension. We observed that greater energy and nutrient intake promotes a better HRQoL, although it does not seem to have a strong direct effect on it. Further research on the influence of energy and nutrient intakes on HRQoL is required. In any case, it should not be forgotten that changes in the diet produced by nutritional intervention could help to improve quality of aging. On the other hand, the use of the Euroqol-5D instrument could help in primary healthcare to identify risk of problems related to malnutrition before they develop.
Acknowledgments
Acknowledgements: The authors acknowledge José Manuel Avila on behalf of Villanueva de la Canada City Council.
Financial disclosure: None of the authors had any financial interest or support for this paper.
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