alvina 36 ABSTRACT Worldwide, the proportion of people aged 60 and over is growing faster than any other age group. It has been well-established that the aging process can be associated with increased susceptibility to chronic conditions, disability, and co-morbidity, which however may be minimized or even partially reversed by physical activity. The assessment of physical activity is becoming an increasingly important component in the evaluation of elderly persons. Nutritional intake and status play an essential role in determining the physical activity level potentially capable of minimizing the health burden of older persons. The objective of this study was to find out whether nutritional intake and status were correlated with physical activity in community-dwelling older persons. The study population included 219 aged 60 to 69 years, of whom complete measures of socio-demographic characteristics, nutritional status, nutritional intake and physical activity were obtained. Serum total protein, albumin, globulin and hemoglobin concentration were measured as nutritional indicators (biomarkers). The nutrient content of food intakes was analyzed and calculated by “Nutrisurvey” software. Analysis indicated that there was a significant correlation between nutritional biomarkers [total protein (r=-0.211; p=0.002) and globulin (r=-0.247; p=0.000)] and physical activity. Compared to other food intakes, intakes of carbohydrate (r=0.241; p=0.001) and animal protein (r=0.149; p=0.027) were significantly correlated with physical activity. Our findings lend support to the existence among healthy older persons of a relationship between nutrional intake and status and physical activity. Key words: Nutritional status, nutritional intake, physical activity, older persons *Department of Community Medicine Medical Faculty, Trisakti University Correspondence Dr. dr. Rina K. Kusumaratna, M.Kes. Department of Community Medicine Medical Faculty, Trisakti University Jl. Kyai Tapa No.260 Grogol - Jakarta 11440 Phone: 021-5672731 ext.2504 Email: rkusumaratna@gmail.com Univ Med 2011;30:36-44. Protein intake as a determinant factor of physical activity in older persons Rina K Kusumaratna* and Adi Hidayat* January-April, 2011January-April, 2011January-April, 2011January-April, 2011January-April, 2011 Vol.30 - No.1 Vol.30 - No.1 Vol.30 - No.1 Vol.30 - No.1 Vol.30 - No.1 UNIVERSA MEDICINA INTRODUCTION Relative to the younger age groups, the group of older persons is steadily growing worldwide, as a result of increased longevity. In 2002, the global population of older persons was around 600 millions and is expected to double by the year 2025. Around 80% of the e l d e r l y w i l l b e l i v i n g i n d e v e l o p i n g countries.(1,2) Indonesia is one of the nations with a large population of older persons and ranks as number five in the world. Thus, the 37 Univ Med Vol.30 No.1 maintenance of a healthy physical and mental state in the elderly population is an important public health challenge now and in the future.(3) A number of clinical and epidemiological studies have produced confirmatory evidence for a relationship between health (physical and mental), nutrition and quality of life. Many studies have strived to find specific nutrients for older persons that could link nutrition with chronic diseases and could impact on health in later life. Other studies have focused on the preventive effects of physical activity on physical health, while others have highlighted the relationship between nutritional intake and status. One of the factors believed to be important for performance of physical activity is the composition of the diet. There are as yet no established criteria for optimal nutritional intakes and requirements in older persons. Nutritional status plays an essential role in determining health status and is potentially capable of minimizing the health burden of older persons. Currently a nutritional transition is occurring on a global scale, due to unhealthy lifestyles of younger people, such as declining physical activity, non-nutritious diets, and smoking. The current trend in developing countries is to eat more fat and more refined diets, which has contributed to increased risk of chronic disease. Social and demographic changes have an impact on older persons, in that the aged population has a great risk of food insecurity and suffers from malnutrition. In facing the expanding older population segment, the WHO and the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University in 1998 jointly set up a list of priority concerns comprising documentation of “the nutritional status of older persons, better definition of their nutrient requirements, and identification of factors affecting dietary intake and nutrient absorption in different cultural and environmental settings”.(4) The normal aging process causes multiple physiological changes that could influence the n u t r i e n t i n t a k e a n d n u t r i t i o n a l s t a t u s o f individuals. Optimal nutrition ensures that the body has sufficient nutrients to maintain its functions, prevent nutritional deficiencies, and delay the onset of degenerative diseases. Recently, there has been a shift in the concept of healthy and successful aging, from an emphasis on number of years to quality of life (QOL) during those years. This shift has led to the view that a healthy lifestyle, specifically optimal food intake and physical activity, are important determinants of QOL and well- being. Exercise is most commonly used for h e a l t h p r o m o t i o n o f o l d e r p e r s o n s , a n d adequate nutritional intake may be expected to produce an improvement in physical activity. A previous study reported that physical activity is not only of benefit in preventing lifestyle- related disease and functional decline in the older persons, but also in decreasing their mortality.(5) These considerations led to the formulation of the aim of the present study, namely to investigate whether nutritional intake and status have a relationship with physical activity among community-dwelling older persons. METHODS Study design A cross-sectional study was carried out in the Mampang Prapatan district, South Jakarta municipality, DKI Jakarta Province from August to October 2007. Study subjects The study enrolled 219 community- dwelling older persons aged 60 to 69 years, who were residents of five sub-districts in the Mampang Prapatan district. Five kelurahan w e r e r a n d o m l y c h o s e n a n d f r o m t h e s e kelurahan were selected 8 hamlets (RW) with high numbers of resident older persons. Subjects were listed and recruited by simple random sampling from the older persons living in the hamlets, especially those who were non- supervised. The inclusion criteria were: male 38 or female persons 60-69 years of age, mobile, independent, able to verbally communicate, willing to join the study and prepared to sign the informed consent form. Exclusion criteria were subjects with dementia or uncontrolled hypertension, and bedridden or physically handicapped persons. Data collection The general characteristics of the subjects i.e. identity of respondents, age, date of birth, address, formal education level, history of occupation, financial support (income and expenses), ethnicity and religion, history of health, housing condition, and life style were recorded by interview using a standardized questionnaire. Anthropometric measurements The subjects were measured as to height, body weight, and waist circumference. Height was measured using a portable microtoise to the nearest 0.1 cm and weight was measured using Sage portable scales to the nearest 0.1 kg. Body mass index (BMI) was calculated as the weight (kg) divided by the square of the height (m2). For Asian populations, BMI is classified into the following categories: underweight (<18.5 kg/m2), normal (18.5–22.9 kg/m2), overweight (23.0–27.5 kg/m2), and obese (>27.6 kg/m2).(6) Waist circumference was measured with the subject wearing light clothing, at a level midway between the lower rib margin and iliac crest, to the nearest cm using a plastic measuring tape. Nutritional evaluation Blood was collected from the antecubital vein in the fasting state in early morning. Serum total protein, albumin, globulin and hemoglobin concentration were measured as nutritional indicators. Dietary intake Dietary intake was assessed using semi- quantitative-food frequency questionnaire (SQ-FFQ), 2 x 24 hours non-consecutive food r e c a l l a n d w e i g h t f o o d . F o r m i n i m i z i n g memory bias and assist the elderly in recalling the foods consumed, the trial used three- dimensional food models in standard portion sizes. The SQ-FFQ and 24-hour dietary recall assessments were done through interviews administered by the nutritionist on home visits. The nutrient content of food intakes was analyzed and calculated by “Nutrisurvey” software.(7) Physical activity Habitual physical activity was calculated using the Short-Form [short version] of the International Physical Activity Questionnaire ( S F - I PA Q ) . T h e I PA Q s h o r t f o r m i s a n instrument designed primarily for population s u r v e i l l a n c e o f p h y s i c a l a c t i v i t y a m o n g adults.(8) The IPAQ was developed as an instrument for cross-national monitoring of physical activity. The SF-IPAQ has been extensively used for measurement of physical activity in the age range of 15 to 69 years, which was the reason for the age limit of 69 years used is the present study. Total physical activity was calculated as MET-minutes/week. Statistical analysis The data analysis was by descriptive statistical methods and bivariate analysis by chi square and independent t tests to compare several variables between males and females. Pearson correlation coefficient was used to determine the relationship between nutrional intake and status and physical activity. A p value of <0.05 was regarded as statistically s i g n i f i c a n t . T h e s t a t i s t i c a l a n a l y s i s w a s performed with the SPSS software package for Windows, version 15 (SPSS Inc., Chicago). Ethical clearance Permission and administrative clearance for conducting the study were provided by the District Health Office and the District Health Center. Ethical clearance was given by the Kusumaratna, Hidayat Protein intake of physical activity 39 Univ Med Vol.30 No.1 Demographic profile and nutritiona l status G ender pa Males n=80 (%) Females n=139 (%) Ag e (yr) * Education (%) Educated Illiterate Marital status (%) Married Wid owed Unmarried Nu tritional status Und erweight Normal Overweight Obese BMI (kg/m2) * Weight (kg) * Height (cm) * Waist circumference (cm) * 64.2 ± 2.9 74 (43.0) 6 (12.8) 67 (68.4) 13 (10.9) 0 (0.0) 13 (26.0) 37 (43.0) 23 (41.1) 7 (25.9) 22.1 ± 3.4 57.2 ± 9.4 160.7 ± 4.3 81.3 ± 10.3 63.7 ± 2.5 98 (57.0) 41 (87.2) 31 (31.6) 106 (89.1) 2 (100.0) 37 (74.0) 49 (57.0) 33 (58.9) 20 (74.1) 21.7 ± 4.4 49.5 ± 11.1 150.8 ± 3.8 77.7 ± 12.2 0.241 0.000 0.000 0.124 0.480 0.000 0.000 0.026 Table 1. Demographic profile and nutritional status by gender (n=219) Note : * Mean ± SD; a p values were derived from χ2 and independent t test Nutritional biomarkers Gender pa Males (n=80) Females (n=139) Hemoglobin (g/dL) Total protein (g/dL) Albumin (g/ dL) Globulin (g/ dL) 14.1 ± 1.5 7.1 ± 0.9 4.0 ± 0.6 3.0 ± 0.5 12.7 ± 1.4 7.1 ± 1.2 3.9± 0.6 3.3 ± 0.7 0.000 0.614 0.121 0.018 Table 2. Mean values of nutritional biomarkers by gender Note: Values are mean ± SD; a p values were derived from independent t test Human Ethics Committee of the Faculty of Medicine, University of Indonesia. RESULTS Demographic profile and nutritional status As shown in Table 1, the majority of participants were females (63.5%) with mean age of 63.7 ± 2.5 years. The underweight category was higher in females (74.0%) compared to males (26.0%). Similarly, there were more overweight females (74.1%) than males (25.9%), although the difference was not statistically significant (p=0.124). Most female older persons (87.2%) were illiterate and 31.6% were married. In male older persons, weight, height and waist circumference were significantly higher compared to females. Nutritional biomarkers Ta b l e 2 c o m p a r e s t h e n u t r i t i o n a l biomarkers between males and females. The hemoglobin concentration was significantly higher among males (14.1 ± 1.5 d/dL) than females (12.7 ± 1.4 g/dL) (p=0.000). However, the globulin concentration was significantly higher in females (3.3 ± 0.7 g/dL) compared to males (3.0 ± 0.5 g/dL) (p=0.018). Total protein, albumin and globulin levels were within the normal ranges in both groups. 40 Table 3. Mean nutritional intakes based on gender Note: Values are mean ± SD; a p values were derived from independent t test Nutritional intakes D a i l y i n t a k e s o f m a c r o n u t r i e n t a n d micronutrients are presented in Table 3. Estimated intakes of energy and nutrients were calculated on the basis of the average value of two non-consecutive 24-hour food recall sessions. From these values the distribution of usual intakes in the population was estimated. Micronutrient intakes were calculated on the basis of the SQ-FFQ. T h e f o l l o w i n g u s u a l i n t a k e s w e r e obtained: mean intake of total energy per day was 1251.1 ± 437.2 Kcal/day in males, or 6 1 . 3 % o f t o t a l e n e r g y i n t a k e b a s e d o n Indonesian recommended daily allowances [IRDA] for males. In females, mean intake of total energy per day was 1056.8 ± 355.8 Kcal/ day or 66.1% of IRDA, carbohydrate 153.3 ± 55.6 g per day, protein 36.2 ± 16.8 g per day and fat 36.3 ±15.6 g per day. Iron, zinc, vitamin C and â-carotene intakes per person per day were 29.4 ± 26.4 mg, 5.4 ± 2.7, 70.0 ± 54.0 mg, and 0.66 ± 0.88 mg, respectively. There were significance differences of total energy, carbohydrate, total protein and animal protein intakes between males and females (<0.05) (Table 3), with higher intakes of carbohydrate, total protein, and animal protein in males. T h e p e r c e n t a g e s o f t h e n u t r i e n t composition in females indicate that average carbohydrate intake accounted for 58.2% of total energy intake, while 10.5% of total energy per day was from protein and 20.4% of total energy per day from fats. In addition, the n u t r i e n t c o m p o s i t i o n o f t h e e l d e r l y w a s moderate for protein (normal range 10-20%), w i t h i n t h e n o r m a l r a n g e o f 5 0 - 6 0 % f o r carbohydrate, and was high in fat (> 25%) in both groups. The vitamin and mineral intakes in both groups were lower than estimated intakes based on IRDA, especially intakes of vitamin E and zinc, which were considerably below IRDA. From these data it is apparent that there were significant differences in nutritional intakes by gender, except for fat and several micronutrients (Table 3). Physical activity Physical activity score in males was 731.5 ± 383.8 MET-minutes/week and in females 590.0 ± 259.7 MET-minutes/week (p=0.001) (data not presented). Kusumaratna, Hidayat Protein intake of physical activity 41 Univ Med Vol.30 No.1 Nutritional status, nutritional intakes and physical activity Table 4 shows the relationship between nutrional intake and status and physical activity. Weight and height were correlated significantly with physical activity (r=0.175; p=0.010 and r=0.169; p=0.010), but BMI and waist circumferences were not significantly correlated with physical activity. The significant correlation between nutritional biomarkers and physical activity comprised serum total protein (r=-0.211; p=0.002) and globulin (r=-0.247; p=0.000). In contrast to other food intakes, intakes of carbohydrate (r=0.241; p=0.001) and animal protein (r=0.149; p=0.027) were significantly correlated with physical activity. DISCUSSION The ideal outcome of longevity is to live through the added years as a healthy individual free of disability and disease, and enjoy a good QOL. However, older persons may expect to experience disability and poor QOL, even if they are apparently healthy. As a rule, older persons s u ff e r f r o m n u t r i t i o n a l d e f i c i e n c e s , ( 9 , 1 0 ) decreased physical activity,(11) decline in health status,(9) decline in cognitive functions,(11) and impaired functional status,(12) all of which ultimately affect their QOL.(13) Hemoglobin, total protein, albumin, and globulin levels are widely used as indicators for screening of nutritional status. The older persons in our study had normal values of hemoglobin, total protein, albumin, and globulin. A study among Italian older persons aged 75 to 85 years and Japanese older women aged 60 to 80 years, showed normal hemoglobin and albumin levels in all subjects.(14,15) Our study results showed a significant relationship between blood albumin concentration and physical activity, which was consistent with the results of a previous study indicating that albumin levels in blood were correlated with walking ability and physical fitness.(16) The study conducted by Chin et al.(17) demonstrated that decreased physical activity was the best indicator for frailty and described its relation to nutritional intake and nutritional status. In contradistinction to the albumin- physical activity relationship, there was no significant correlation between energy intake and physical activity in our study. Although blood biomarkers are important for determining nutritional status, a more important point to consider is dietary or nutritional guidance to older persons for ensuring maintenance of proper dietary intakes, especially intakes of protein. It is known that both exercise and nutrition are important in promoting health in elderly people. In health promotion, the relationship between nutritional intake and/or status and physical activity has to date not been adequately clarified. The present study showed that total energy intakes of both females and males were lower than estimated energy requirements based on IRDA, with moderate protein and normal carbohydrate intakes but high intakes of fat, relative to IRDA, for persons aged 60 years and over. Vitamin and mineral intakes in both groups were also lower than IRDA, especially for intakes of vitamin E and zinc which were considerably below IRDA. Our study results Table 4. Relationship between nutritional status and intake and physical activity in all subjects (n=219) a p values were derived from Pearson correlation test 42 differed from a study in Japan on female subjects aged 60 to 82 years, which showed that intakes of macronutrients, micronutrients and v i t a m i n s s a t i s f i e d e s t i m a t e d e n e rg y requirements based on the Japanese Dietary Intake Reference 2005.(15) Intake of antioxidants (vitamin C, â-carotene, vitamin E, and trace m i n e r a l s s u c h a s z i n c ) i s e s s e n t i a l f o r maintaining health and physical activity in old age. According to findings from one of the studies of the Italian InCHIANTI (Invecchiare i n C h i a n t i ) p r o j e c t , p l a s m a a n t i o x i d a n t concentration significantly correlates with physical performance and leg extension strength in older persons.(18) Socio-economic factors are also important as underlying determinants of morbidity, mortality and malnutrition, including m i c r o n u t r i e n t d e f i c i e n c y. E d u c a t i o n a l background can be used to assess the potential vulnerability of a population with poor dietary patterns. In this study only 21.5% of illiteracy was found, and therefore other factors may have affected the dietary pattern. In urban areas, such as Mampang Prapatan, the population depends heavily on cash income, and employment can be a useful indicator of standard of living. In general, older people might be at risk of malnutrition due to impaired energy intake, social isolation or decreased income. In the present study, socio-economic factors, including source of income and employment, could be also used as indicators to identify those older persons at high risk for micronutrient deficiency. Overall, the diet of the subjects conformed to that of other developing nations, being largely composed of foods of plant origin. Their diet includes few animal protein sources, such as meat or poultry, since these are expensive and older persons may be unable to afford them on a regular basis. The association between poverty and nutrition has long been recognized, because p o o r p o p u l a t i o n s o f t e n r e l y h e a v i l y o n monotonous plant-based diets low in animal products. In addition, some of the older persons may have difficulties in mastication due to dental problems, such that most of them substitute the softer tofu or tempeh for relatively tough animal protein. Malnutrition in older p e o p l e i s a n i m p o r t a n t p r o b l e m a n d i s encountered in both community-dwelling and institutionalized older persons. The risk and prevalence of malnutrition rise proportionally w i t h a g e , m a k i n g t h e m a n a g e m e n t o f malnutrition among older people an urgent public health need, that is also beneficial from an economic viewpoint. In general, nutritional requirements change with increasing age. Older people are less efficient in processing and metabolizing their foods, and require lesser amounts of energy. They therefore should consume nutrient-dense f o o d s , i n w h i c h s m a l l s e r v i n g s p r o v i d e substantial amounts of macro- and micro- nutrients. Inadequate food intake leads to undernutrition among older persons that is difficult to reverse, because low food intakes are likely to increase their risk of energy and nutritional deficiency. Ideally, older persons should have balanced and varied intakes of macro- and micronutrients for optimum health. However, most subjects in this study had a total energy intake of 63.7%, which is lower than the minimal requirement (80%) of IRDA for persons aged 60+ years. Although in absolute terms the total energy intake of both genders were significantly d i ff e r e n t , i t w a s m o s t l y i n a d e q u a t e a n d unbalanced. Most macro- and micronutrient intakes were lower than IRDA for age 60+ years, especially intakes of vitamin C, vitamin E and zinc, which were far below IRDA. Therefore it appears that the diet of the study subjects was relatively poor in macronutrients and energy, but definitely deficient in vitamins and minerals. These results are consistent with those of several studies reporting that 50% of older persons have a micronutrient intake of less than the daily recommended intake, while 10–30% has marginal levels of micronutrients.(9,19) Therefore it should be emphasized to older persons to Kusumaratna, Hidayat Protein intake of physical activity 43 Univ Med Vol.30 No.1 consume sufficient amounts of animal protein, b o t h f o r i t s r e a d y a b s o r b a b i l i t y a n d micronutrient content. An adequate protein intake results in a positive nitrogen balance, thus accelerating protein synthesis. Our study did not find a correlation between BMI and physical activity. This agrees with a Swedish study on subjects 60–84 years of age, where no significant difference was found between BMI and leisure time physical activity, both among subjects born in Sweden as well as among Swedish residents born in Iran.(21) Furthermore, in our study a significant c o r r e l a t i o n w a s o b s e r v e d b e t w e e n carbohydrate and animal protein intake with physical activity. Similar results were found in elderly Japanese women,(15) which may be explained by the fact that among ordinary older people nutritional intake may relate to physical activity, regardless of the subject’s body composition. Muscle mass gradually declines after age 50 years, and muscle loss leads to muscle weakness; greater risks of falls, fractures, disability, and loss of independence.(22) Some of the age-related muscle weakness and muscle loss is due to physical inactivity, and as such can be reversed or at least minimized through increased physical activity. Strength training can be an effective way for older persons to increase muscular strength and improve balance, and may assist the elderly to cope with a variety of chronic conditions; thus physical activity may have a preventive effect against disease and immobility.(23) As the world population is growing older and older, the increasing number of older people will present economic and social problems over the next decade. An important goal of research today is to identify possible strategies for ensuring the health of the elderly people in the near future in order to reduce social and economic expenditure. Our data showed that nutrition is correlated with physical activity. Although links between diet, physical activity, and risk of chronic disease have been well documented, more needs to be known about the p o s s i b l y r e c i p r o c a l e ff e c t s o f r e g u l a r l y performed physical activity and improved diet in older persons.(24,25) Several limitations of our study should be mentioned. The cross-sectional design of the study did not permit us to evaluate the causality of daily nutrient intakes on physical activity. Further longitudinal studies are needed to evaluate the role that nutrition status and intake may have on physical performance in older persons. The study population tended to be overweight, which prevented us from assessing the effect of very poor nutrition and may have influenced our findings. To better identify the effects of nutritional intake on physical activity, it may be useful to compare one group of persons with undernutrition with a control group of normal nutritional status. Finally, another l i m i t a t i o n o f o u r s t u d y w a s t h e l i m i t e d assessment of biomarkers. The evaluation of both dietary intake estimates and biomarkers would have been the ideal combination. CONCLUSIONS The present study found differences between actual and recommended dietary patterns of older persons in Indonesia, with both genders having nutrient and energy intakes below IRDA. The protein intake have a relationship with physical activity in healthy elderly people. Albumin blood levels as a targeted marker of nutrition status in blood significantly correlated with physical activity. ACKNOWLEDGEMENT The authors wish to thank all the elderly subjects participating in the study, and the Mampang Prapatan Health Center, South Jakarta for their cooperation. The present study was supported by the Faculty of Medicine, Trisakti University. 44 REFERENCES 1. UNFPA. Population Ageing in East and South- East Asia: current situation and emerging challenges. 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