Rita K 179 *Department of Community Medicine, Medical Faculty Trisakti University Correspondence adr. Rina K. Kusumaratna, M.Kes. Department of Community Medicine, Medical Faculty Trisakti University Jl. Kyai Tapa No.260 Grogol Jakarta Barat Phone: 021-5672731 ex. 2504 Email : rkusumaratna@yahoo.com Universa Medicina 2007; 26: 179-85 UNIVERSA MEDICINA Oktober-Desember 2007Oktober-Desember 2007Oktober-Desember 2007Oktober-Desember 2007Oktober-Desember 2007 Vol.26 - No.4 Vol.26 - No.4 Vol.26 - No.4 Vol.26 - No.4 Vol.26 - No.4 Dietary zinc intake and zinc status differences between male and female elderly of South Jakarta community Rina K. Kusumaratna*a, Oktavianus Ch.Salim*, and Novia I. Sudharma* ABSTRAK INTRODUCTION The elderly have a greater risk of zinc deficiency compared to younger adults. This condition may be reflected by a lowered zinc intake and reduced zinc absorption in the elderly. The aim of the study was to explore the dietary zinc intake and zinc status differences between male and female elderly. METHODS A cross-sectional study was conducted included eighty-nine free-living subjects, aged above 60 years, apparently healthy and ambulatory. A two day and non consecutive diet record was used to assess energy and nutrient intake of the elderly. It was combined with a semi-quantitative food frequency questionnaire (SQ-FFQ), with food model that was also used to quantify the food pattern on each food frequency item. Serum zinc concentrations were measured by using atomic absorption spectrum photometry. RESULTS The total energy intake and normal serum zinc concentration in both genders of free-living elderly were mostly below the recommended dietary allowance. The mean serum zinc concentration did not differ significantly between female (13.7 µmo/l) and male elderly (13.9 µmo/l). Mostly the intake of zinc was below two thirds of the RDA it presented on intake of zinc in males was much less compared to female. Overall, the prevalence of zinc deficiency appeared low among the free-living elderly in South Jakarta. CONCLUSIONS The prevalence of zinc deficiency was relatively low in healthy elderly. Prevalence of zinc deficiency and zinc intake were lower in female compared to male elderly. Keywords: Zinc, intakes, free-living, elderly 180 Kusumaratna , Salim, Sudharma Zinc intake and zinc status in elderly *Bagian Ilmu Kedokteran Komunitas Fakultas kedokteran Universitas Trisakti Korespondensi adr. Rina K.Kusumaratna, M.Kes. Bagian Ilmu Kedokteran Komunitas, Fakultas Kedokteran Universitas Trisakti Jl. Kyai Tapa No.260 Grogol Jakarta Barat 11410 Telp. 021-5672731 Eks.2504 Email: rkusumaratna@yahoo.com Universa Medicina 2007; 26: 179-85. LATAR BELAKANG Risiko terjadinya defisiensi seng pada lanjut usia (lansia) lebih besar dibandingkan usia dewasa muda. Keadaan ini direfleksikan oleh rendahnya asupan dan absorpsi seng pada lansia. Penelitian ini bertujuan untuk membedakan asupan dan status seng antara lansia laki-laki dan perempuan. METODE Sebanyak 89 lansia berusia 60 tahun ke atas berbadan sehat dan mampu melakukan aktifitas secara mandiri diikut sertakan pada studi yang menggunakan rancangan potong silang (cross-sectional). Asupan energi total dan kadar seng diukur menggunakan catatan diet selama dua hari berturut-turut. Pengukuran ini dikombinasi dengan semi-quantitative food frequency questionnaire (SQ-FFQ) dan model makanan. Kadar seng dalam serum diukur menggunakan atomic absorption spectrum photometry. HASIL Rata-rata kadar seng dalam serum pada lansia perempuan (13,7 µmo/l) tidak berbeda bermakna dengan lansia laki-laki (13,9 µmo/l). Asupan energi total dan kadar seng dalam serum lebih rendah dibandingkan dari jumlah yang dianjurkan baik pada lansia laki-laki maupun perempuan. Sebagian besar asupan seng besarnya duapertiga lebih rendah dari angka kecukupan gizi (AKG), asupan seng pada lansia laki-laki lebih rendah dibandingkan lansia wanita. Secara keseluruhan prevalensi defisiensi seng di antara komunitas lansia di Jakarta Selatan adalah rendah. KESIMPULAN Studi ini menunjukkkan prevalensi defisiensi seng yang relatif rendah. Asupan dan status seng lebih rendah pada lansia perempuan dibandingkan lansia laki-laki. Kata kunci : Seng, asupan, komunitas, lanjut usia Perbedaan asupan dan status seng antara laki-laki dan perempuan lanjut usia di komunitas Jakarta Selatan Rina K. Kusumaratna*a, Oktavianus Ch.Salim*, dan Novia I. Sudharma* ABSTRACT INTRODUCTION In general, the elderly due to inadequate m i c r o - n u t r i e n t i n t a k e a r e s u s c e p t i b l e t o physical inactivity, infection, and chronic diseases. Inadequate nutrition intake will have an impact on an individual’s health status. Nutritional disorder might also develop not just because of inadequate intake, but also due to the body’s inability to utilize nutrients; even though, the individual consumes appropriate a m o u n t s a n d a v a r i e t y o f f o o d s . G e n d e r differences of choice in nutrient intake among the elderly could indicate differences in values o f h e m a t o l o g i c a l a n d c l i n i c a l a n a l y s i s . Micronutrient deficiency such as iron, vitamin 181 A and iodine are well- established in developing countries. Presently, zinc deficiency has also been recognized by a number of experts as an important public health issue. Clinical zinc deficiency was first described in early 1960s, and since then it has been recognized as a c o m m o n d e f i c i e n c y i n h u m a n s . ( 1 , 2 ) Z i n c deficiency has been observed in animal and human studies that could decrease resistance to infectious diseases. Zinc as one of the essential trace element has recently been of i n t e r e s t b e c a u s e o f i t s f u n c t i o n i n t h e maintenance of human health and nutrition statuses. Elderly individuals are at greater risk of zinc depletion than younger adults that might be reflected in lower zinc intake and reduced zinc absorption due to aging. Zinc deficiency has also been reported in the European ZENITH study that showed zinc deficiencies in healthy, free-living, late middle-age and older persons, even with a low prevalence.(3) Study in central Japan also found zinc deficiency in free-living of elderly.(4) Major sources of zinc are animal based products that generally are consumed in small amounts; moreover, the Asian diet which is based on whole-grain cereals and other plant foods is less bio-available due to its relatively high content of phytate, a compound that inhibits zinc absorption. The elderly who avoid flesh foods due to some reason, might be at risk of poor zinc status because of its reduced bioavailability in the daily diet. Vitamin and mineral deficiency (VMDs) as stated in a United Nation report, includes deficiency of vitamin A, iron, iodine, zinc, folic acid that have affected over 2 billion people in the world. This condition is mostly caused by diets deficient in vitamins and minerals that the body needs, and become worse by losses or poor absorption related to illness. These situations are found in every part of the world, and the global databases report has estimated that 20% of the world’s population is at risk of zinc deficiency.(5) Zinc supplementation could be a low cost strategy in improving physiological and cognitive functions in the elderly. The aim of this study was to compare the intake and status of zinc between male and female elderly, and whether there is a difference in dietary intake based on gender. METHOD Research design A cross-sectional study was conducted in a sub-district health center in South Jakarta. Subjects Using demographic information system t h a t c o n t a i n e d t h e h e a l t h c e n t e r p a t i e n t database, potentially eligible elderly were identified and invited to participate in the study. The participants were residents living in the d i s t r i c t a n d t h e i r m a i n o c c u p a t i o n w a s pensioner or retired government employee or house wife. The number and selection of the elderly was determined by using a simple random sampling on a finite population. Three hundred persons aged 60 years and older was gathered by cluster random sampling from 7 villages health center which was under the jurisdiction of Mampang Prapatan District Health Center. These were later screened, and finally only one-hundred and fifty elderly were assessed on their dietary intake and fasting blood sample. The eligibility of subjects in the study was gender both male and female, aged 60 years above, ambulatory and apparently h e a l t h y d u r i n g e x a m i n a t i o n . E a c h o f t h e p a r t i c i p a n t s w a s r e q u e s t e d t o f i l l o u t a n informed consent form to ensure that they agreed to fully participate in the study. Data collection was conducted from November 2005 to February 2006. However, from the 150 elderly who were eligible for the study only eighty-nine subjects had complete records that Universa Medicina Vol. 26 No.4 182 Kusumaratna , Salim, Sudharma Zinc intake and zinc status in elderly could be matched between their biological analysis sample and the dietary assessment. Biological measurements All blood samples were collected after overnight fasting. For zinc analysis, samples were collected using serum of blood in a tube of zinc-free nitric acid, and diluted with zinc-free water. Samples were centrifuged at a maximum speed of 15,000 rpm for 5 minutes. Serum zinc w e r e d e t e r m i n e d b y a t o m i c a b s o r p t i o n s p e c t r o p h o t o m e t r y ( A A S ) w i t h Z e e m a n background corrected (GBC 933 AA, with ë 213, 9 nm). Dietary intake A two day and non consecutive diet record was used to assess energy and nutrient intake of the elderly. It was combined with a semi- quantitative food frequency questionnaire (SQ- FFQ), with food model that was also used to quantify the food pattern on each food frequency item. The calculated nutrient intake of the sample was compared with the “Indonesian recommended dietary allowance” (Indonesian RDA) for the particular age and gender group, (female 1,850 kcal and male 2,200 kcal). The amount of various food consumption reported was recorded then converted into energy and nutrient intakes per day. Values less than two thirds of the recommended intake are considered as a risk of deficiency of the respective nutrients. The RDA of zinc intake was based on Recommended RDAs for zinc for Southeast Asia.(6) Statistical analysis Data were reported as mean, standard deviation and frequency distribution. Food c o n s u m p t i o n a n a l y s i s u s e d n u t r i s u r v e y calculation. All statistical analysis was done with SPSS Windows version 11.5. Normal distribution of data was checked using the Kolmogorov- Smirnov test. Independent-t test was used to compare the zinc intake and concentration between male and female elderly. Ethical clearance Study protocol was reviewed and sanctioned by the Medical Faculty Ethics Commission. RESULTS The result of One-Sample Kolmogorov Smirnov test presented that the distribution of the d a t a w a s n o r m a l . T h e s a m p l e s w e r e predominately females than males (69.7% vs 30.3%) and 85.4% were mostly 60–70 years in both gender. The total energy intake was mostly below of the recommended dietary allowance based on the Indonesian RDA in both gender, 57.7% females and 48.7% males respectively. The intakes of zinc between females and males were inadequate compared to the RDA. Male was twice more likely than female categorized in the less than two thirds of the RDA. There were similar findings on zinc sources intake between dietary recall and Semi-Quantitative Food Frequency (SQ FFQ) (Table 1). No significantly difference between energy and zinc intake and gender. Note : zinc RDA/AKG (mg/day) a=4.4 ; b=6.5 Females (n = 62) Males (n Energy (kcal/d) 1068.98 ± 313 1072.08 Zinc (mg/d) 4.11 ± 1.8 3.9 ± <2/3 KG (%) 25.8%a 70% Table 1. Mean daily energy and zinc intakes of free-living elderly by gender (mean ± s.d.) 183 The mean serum zinc concentration did not differ significantly between female (13.7 µmo/ l) and male elderly (13.9 µmo/l). The percentage of subjects based on gender that showed a serum Zn concentration below 10.7 µmol/l, which is considered as the cut-off level for zinc deficiency was 3.2% in females and 7.4% in males. There were more male subjects that had lower serum zinc concentration compare to female, almost double, with an average of 4.5% for all subjects. (Table 2) DISCUSSION Zinc is an essential trace element for human and all forms of life, thus in the elderly zinc has an essential function in immunity, age related changes of bone mass, cognitive functions and oxidative stress, and a leading cause of blindness in people over the age of 65 years. One function of zinc as a micronutrient is as antioxidant that has the capability of protecting cells from the damaging effects of free radicals released in the body. Other studies of human subjects have reported that zinc deficiency in individuals has declined the sensitivity of taste bud and could be restored by zinc supplementation.(4,7-9) This study of free living elderly showed that most of the subjects had normal serum zinc concentration. However, the mean daily intake of zinc sources was mostly below two thirds of the RDA for older people above 60 years, namely 37% females and 74% males. Based on the result as shown in Table 1, it could be reported that free-living elderly dominantly had less zinc intake. This was due to the source of zinc intake mainly from the daily food diet, there was no i n d i c a t i o n o f a n y o t h e r a d d i t i o n a l z i n c supplements being used. The same results were shown in a study conducted by Sibai(11) and Ervin RB. (12) However, the present study showed different results compared to the study in Japan b y K o g i r i m a e t a l , ( 4 ) t h e Z e n i t h s t u d y b y Andriollo Sanchez M et al,(3) Galan P, et al(13) and Paik HY et al.(14) In the last study, the intake of zinc of the subjects was adequate. Zinc intake of females was higher compared to males (4.11 ± 1.8 mg/d vs 3.9 ± 1.7 mg/d ). This data could reflect the specific differences in dietary habits. From dietary assessment, female elderly consumed more animal protein as a source of zinc than males (33.38 ± 15.3 mg/day vs 28.86 ± 12.8 mg/day). I n t h e p r e s e n t s t u d y, s e r u m z i n c concentration in the female and male elderly were 13.67 ± 2.3 µmol/l vs 13.98 ± 2.6 µmol/l, respectively. This result was almost similar to o t h e r s t u d i e s t h a t h a v e b e e n c o n d u c t e d earlier.(3,14,16,17) Those results did not reflect the w i d e r a n g e o f d i f f e r e n c e s i n s e r u m z i n c concentration values between the genders. Percentage of elderly that were below the cut-off level for zinc deficiency showed that males were twice more lower than females. Is the risk of zinc deficiency in males much higher than females? To explore this finding further, a study should be done to prove this tendency based on the baseline data of the present study on assessing zinc status of the healthy free-living elderly. The result of this study also showed that there was a low prevalence of zinc deficiency Universa Medicina Vol. 26 No.4 Table 2. Zinc status in free-living elderly by gender (mean ± s.d.) Females (n = 62) Serum Zn (µ mol/l) 13.7 ± 2.3 <10.7 µ mol/l (%) in serum 3.2% 184 Kusumaratna , Salim, Sudharma Zinc intake and zinc status in elderly in the free-living elderly. The same result was shown in The ZENITH study, that showed a low prevalence of zinc deficiency but differed in the Japanese study,(2) that reported a high p r e v a l e n c e o f z i n c d e f i c i e n c y a m o n g t h e Japanese aged, and the De Jong et al(17) study in New Zealand also reported that twelve percent among of New Zealand elderly women had zinc deficiency. The present data showed contradictive findings with the first study that was conducted in five municipalities in Jakarta that assessed the zinc concentration of free- living elderly. The study reported that 67% of f r e e - l i v i n g e l d e r l y i n J a k a r t a h a d z i n c deficiency. I n o u r s a m p l e s , t h e r e w e r e a l s o contradictive findings between the results of zinc intake and corresponding zinc concentration. Majority of the elderly were below 2/3 of RDAs zinc intake, but had above the cutoff level of zinc concentration. There could be a bias in assessing the food intake of the elderly, such as memory bias. Because all the subjects were above 60 years aged, then they had to memorize what they had been eating in a day and the next day. For the elderly to memorize two days and non consecutively on what they had eaten could have created difficulties for the elderly. Thus, the differences of the findings could be due to lack of memory on the part of the subjects. CONCLUSION The findings of the study in free-living e l d e r l y i n S o u t h J a k a r t a s h o w e d a l o w prevalence of zinc deficiency but had similar results with their corresponding zinc intake daily. For further study, assessing of dietary intake should use food weighing namely what the subject actually ate daily to reduce errors caused by memory bias. Dietary assessment instruments used must also accurately capture and reflect elderly dietary intakes. ACKNOWLEDGEMENT This study was conducted with the support of funding from the Medical Faculty of Trisakti University. The dietary survey was supported b y S E A M E O - T R O P M E D n u t r i t i o n a l f i e l d surveyor. The author would like to thank all of those who participated and assisted in the study. References 1. Prasad AS. Zinc: Mechanism of host defence 1-3. J Nutr 2007; 137: 1345-50. 2. Hambidge KM, Krebs NF. Zinc deficiency: a special challenge 1-2. J Nutr 2007; 137: 1101-6. 3. Andriollo-Sanchez M, Hininger-Favier I, Meunier N, Toti E, Zaccaria M, Brandolini-Bunlon M, et al. Zinc intake and status in middle-aged and older European subjects: the ZENITH study. Eur J Clin Nutr 2005; 59 (Suppl 2): S37-41. 4. Kogirima M, Kurasawa R, Kubori S, Sarukura N, Nakamori M, Okada S, et al. 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