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Determination of Dietary Status as a Risk Factor of Cardiovascular Heart Disease in Turkish Elderly People a
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Alev Keser , Nurcan Yabanci Ayhan , Pelin Bilgiç , Muhittin Tayfur & Işil ŞImşek
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Department of Nutrition and Dietetics, Ankara University, Ankara, Turkey b
Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey c
Department of Nutrition and Dietetics, Başkent University, Ankara, Turkey
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Basic Pharmaceutical Sciences, Gazi University, Ankara, Turkey Published online: 20 Jan 2015.
To cite this article: Alev Keser, Nurcan Yabanci Ayhan, Pelin Bilgiç, Muhittin Tayfur & Işil ŞImşek (2015) Determination of Dietary Status as a Risk Factor of Cardiovascular Heart Disease in Turkish Elderly People, Ecology of Food and Nutrition, 54:4, 328-341, DOI: 10.1080/03670244.2014.992520 To link to this article: http://dx.doi.org/10.1080/03670244.2014.992520
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Ecology of Food and Nutrition, 54:328–341, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.992520
Determination of Dietary Status as a Risk Factor of Cardiovascular Heart Disease in Turkish Elderly People ALEV KESER and NURCAN YABANCI AYHAN Department of Nutrition and Dietetics, Ankara University, Ankara, Turkey
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PELIN BILGIÇ Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
MUHITTIN TAYFUR Department of Nutrition and Dietetics, Ba¸skent University, Ankara, Turkey
I¸SIL S¸ IM¸SEK Basic Pharmaceutical Sciences, Gazi University, Ankara, Turkey
This study was performed to determine the status of diet as a risk factor of cardiovascular heart disease in a group of Turkish elderly people. We performed a cross-sectional study using the data of voluntary participants aged between 65–74 years old. Participants completed 3-day diet records. Of participants, 64.1% of the men and 62.2% of the women reported their daily dietary fat intake as being > 30% of total energy (p > .05). More than 20% of these elderly respondents’ daily intakes of vitamin E, vitamin B6 , vitamin B12 , and folate were found to be under the recommended values. As a result, the total fat intake of these elderly people was found to be high; while their intake of fiber and vitamin B6 , vitamin B12 were found to be low, compared to American Heart Association recommendations. In conclusion, it is recommended that developing sufficient and balanced diets may decrease cardiovascular risk factors. KEYWORDS cardiovascular risk factors, diet, elderly, nutrient intake
Address correspondence to Nurcan Yabancı Ayhan, Department of Nutrition and Dietetics, Ankara University, Aktas Kav¸sa˘gı No. 5, 06340 Ankara, Turkey. E-mail: nyabanci@ gmail.com 328
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The population of adults over 65 years of age is growing rapidly worldwide. In 2009, 21% of the population in developed countries was aged over 60 years, and it is projected that by 2050 the proportion of those over 60 years of age will have increased to 33% (Department of Economic and Social Affairs 2009). According to the Turkish Statistical Institute, the elderly population ratio in Turkey was 7.7% in 2007 and it is estimated to rise to 10.2% in 2023, 20.8% in 2050, and 27.7% in 2075 due to projected population; Turkey is thus predicted to be among the countries having an elderly population in a very high ratio in the future (TÜI˙ K 2013). Cardiovascular diseases (CVD) are among the serious public health problems in Turkey. Over 230,000 new coronary cases occur in a year, according to the study Cardiovascular Diseases and their Risk Factors in Turkish Adults. This study also indicates that in Turkey approximately 160,000 men and 120,000 women die each year, and of these the deaths of 61,000 men and 66,000 women are coronary originate (Onat et al. 1996). Risks for CVD also increase by age (Stanner 2009). The prevalence of coronary heart diseases is one in five elderly adults between 60–69 years of age, and one in four elderly adults aged 70 years and over (Onat et al. 1996). Dietary intake is thought to exert a great influence on the risk of CVD. Because lifestyle factors such as smoking, physical activity, and nutrition play important roles in the onset and progress of CVD, they may be especially important in the elderly, who are at an increased risk of developing chronic diseases (de Groot at al. 2004). Results of some studies indicated that interventions to change nutritional habits can be highly effective in reducing CVD risk. Diets low in saturated fat and cholesterol are associated with lower rates of CVD. Replacing saturated with polyunsaturated fatty acids (PUFA) reduced cardiovascular events in some early trials. Folate, vitamins E, B6, B12, and dietary fiber are emerging as potentially useful protective factors (Fung et al. 2004; Liu et al. 2000). The American Heart Association (AHA) guidelines, in their revised form, advocate a limitation of saturated fatty acids (SFA) to less than 10% of total energy, and daily consumption of total cholesterol to less than 300 mg. The AHA guidelines also provide recommendations for several other parameters, including fiber (10 g/1000 kcal). AHA has made some suggestions about nutrition and lifestyle to reduce the CVD risks (Kris-Etherton et al. 2001). This study was planned to evaluate the cardiovascular risk factors according to AHA depending on diet in a group of Turkish elderly people.
METHODS Participants A cross-sectional study was conducted on total of 369 elderly people (184 men, 185 women), between the ages of 65–74 (68.3 ± 2.8) years.
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Participants live in the district of Emek and Bahcelievler/Ankara where the elderly population is high. Data were collected by face-to-face interviews between September and December 2011. All participants were healthy by point of cognitive function (no participant had any cognitive or health problem that would affect the responses). All studies were conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Ethics Committee of Gazi University (Ethics approval code 2011/219). Written informed consent was obtained from all study participants.
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Anthropometric Measurements Weight was measured by electronic scales to the nearest 0.1 kg and height was measured to the nearest 0.1 cm a wall-mounted stadiometer while participants were wearing light clothing and no shoes. Body mass index (BMI) (kg/m2 ) was evaluated (classified) according to World Health Organization (WHO) standards. Underweight was diagnosed when the BMI was less than 18.5 kg/m2 ; normal weight when the BMI was between 18.5–24.9 kg/m2 ; whereas overweight was diagnosed when the BMI was between 25.0–29.9 kg/m2 ; and when BMI exceeded 29.9 kg/m2 , then participants were classified as obese (WHO 1997).
Nutritional Assessment The participants and their family members were taught by the dietitian how to keep accurate food records. The first day of the record consisted of a 24-hour recall which was used to instruct participants in the degree of detail needed for the record. Participants recorded accurately and completely the type and quantity of all foods and liquids consumed, as well as recipes for prepared food items and method of food preparation. On rare occasions when it was not possible to weigh food, consumed serving size was estimated from either product names, the place of food consumption, standard weights of food items or from the portion size that was determined from a picture booklet of 120 photographs of foods (Rakıcıo˘glu et al. 2009). Participants recorded the type and quantity of food and beverages consumed for 2 weekdays and 1 weekend day, which were consecutive; in total, 3-day food intake records were obtained from each participant. The accuracy and completeness of the food records were checked and completed by dietitians and participants. The average energy (kcal), total fat, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), dietary cholesterol and fiber, vitamins E, B6 , B12, and folate intakes were analyzed using BeBI˙ S 6.1 software (Nutrition Information System), which
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is based on several international and national food-composition tables. The energy and nutrient intakes of the participants were compared to the Recommended Dietary Allowances (RDA) (Subcommittee on the Tenth Edition of the RDAs 1989), Dietary Reference Intake (DRI) (Yates, Schicker, and Suilor 1998), and AHA recommendations (Kris-Etherton et al. 2001). The atherogenic indexes of polyunsaturated fatty acids–saturated fatty acids ratio (P/S) and cholesterol-saturated fat index (CSI) (NCEP 1992) were determined using the following equations: P/S: (total PUFA/total SFA); CSI: (0.01 xg SFA) + (0.05 xmg cholesterol) (Connor et al. 1989).
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Statistical Analyses Data were analyzed by using SPSS statistical software package. Continuous variables were described by using mean± standard deviations. Frequencies and percentages were used as descriptive statistics for categorical variables. Normally distributions were evaluated by one sample Kolmogorow Smirnov test. Inter-group comparisons performed with Chi-square and t-tests; and the statistically significant p level was set at .05.
RESULTS The average age of the elderly people in the study was 68.3 ± 2.8 years for the men, and 68.1 ± 2.8 years for the women. While weight and height were higher for men than women (p < .001), BMI was higher for women than men (p < .05). The prevalence of obesity was 17.4% in men, 23.8% in women (table 1). Daily dietary energy, the percentages of energy from total fats, SFA, and MUFA, dietary cholesterol, and vitamin E intake were higher in men than women (p > .05). In addition to these, vitamin B12 intake is statistically higher in men (3.5 ± 3.3 mcg) than in women (2.6 ± 3.4 mcg) (p < .05) (table 2). The percentage of elderly exceeding the dietary recommendations of the AHA for total fat, fatty acids, and dietary cholesterol is presented in table 3. In addition, the percentage of elderly who did not meet two thirds of RDA for vitamin E, vitamin B6 , and folate and the recommendation for dietary fiber is presented. According to the recommendation of AHA, risk factors related to dietary intakes were higher in men except for MUFA, vitamin B12, and folate. Total fat intake of 63.1% of the elderly adults in this study was high, dietary cholesterol intake of 46.6% of participants was over the recommendations of AHA, and there was no gender difference (p > .05).
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TABLE 1 The Evaluation of Age, Weight, Height, BMI, and Obesity Prevalence according to Gender
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Age (y) Weight (kg) Height (cm) BMI (kg/m2 )
Underweight Normal weight Overweight Obesity ∗
Men (n = 184) Mean ± SD
Women (n = 185) Mean ± SD
p
68.3 ± 2.8 75.7 ± 10.9 169.5 ± 7.5 26.3 ± 3.4
68.1 ± 2.8 69.4 ± 12.7 159.2 ± 6.8 27.4 ± 4.8
.446 .00∗ .00∗ .019∗
Men (n = 184)
Women (n = 185)
Total (N = 369)
n
%
2 66 84 32
1.1 35.9 45.7 17.4
n 1 62 78 44 χ 2 = 2.573, p
%
N
%
0.5 33.5 42.2 23.8 = .462
3 128 162 76
0.8 34.7 43.9 20.6
p < .05.
TABLE 2 Mean Values of Daily Energy and Nutrient Intake according to Gender Energy and nutrient
Men (n = 184) Mean ± SD
Women (n = 185) Mean ± SD
Total (N = 369) Mean ± SD
p
Energy (kcal) Total fat (TE%) SFA (TE%) MUFA (TE%) PUFA (TE%) P/S CSI Dietary cholesterol (mg) Fiber (g) Vitamin E (mg TE) Vitamin B6 (mg) Vitamin B12 (mcg) Folate (mcg)
1645.8 ± 15.4 34.9 ± 10.9 10.4 ± 4.3 11.8 ± 4.1 10.8 ± 6.1 1.2 ± 0.7 10.7 ± 9.6 179.9 ± 148.2 21.8 ± 8.6 22.1 ± 16.2 1.4 ± 0.5 3.5 ± 3.3 348.5 ± 121.2
1585.9 ± 575.9 33.7 ± 10.5 9.9 ± 4.0 11.0 ± 4.3 10.8 ± 6.0 1.3 ± 0.9 9.9 ± 9.4 163.1 ± 149.6 23.2 ± 11.1 21.7 ± 20.8 1.4 ± 0.6 2.6 ± 3.4 356.2 ± 131.1
1615.7 ± 95.9 34.4 ± 10.7 10.2 ± 4.2 11.4 ± 4.2 10.8 ± 6.0 1.2 ± 0.8 10.3 ± 9.4 171.5 ± 148.9 22.5 ± 9.9 21.9 ± 18.7 1.4 ± 0.6 3.0 ± 3.4 352.3 ± 126.2
.335 .260 .357 .066 .983 .412 .407 .277 .180 .829 .401 .007∗ .556
Note. SFA = Saturated fatty acids; MUFA: = Monounsaturated fatty acids; PUFA = Polyunsaturated fatty acids; P/S = Polyunsaturated fatty acids/Saturated fatty acids; CSI = Cholesterol-saturated fat index. ∗ p < .05.
DISCUSSION In Turkey, 48% of all deaths are related to CVD (Sa˘glık Bakanlı˘gı 2006). Obesity as an important factor of CVD was also supported by a study by Kvamme and colleagues (2010) on adults over the age of 65. In recent years, the rise in obesity is alarming. The prevalence of obesity in Americans 65–74 years old is 41.5% and 40.3% in men and women,
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TABLE 3 Percentage of Elderly People Not Meeting AHA Recommendations for Cardiovascular Disease Prevention Men (n = 184)
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Dietary risk factors Total fat > 30% TE SFA > 10% TE MUFA < 10% TE PUFA < 7% TE P/S < 1 Cholesterol > 100 mg/1,000 kcal CSI > 25 Fiber < 10 g/1,000 kkal Vitamin E < 2/3 RDA Vitamin B6 < 2/3 DRI Vitamin B12 < 2/3 DRI Folate < 2/3 DRI
Women (n = 185)
Total (N = 369)
n
%
n
%
N
%
p
118 85 67 57 92 91 17 37 44 67 62 44
64.1 46.2 36.4 31.0 50.0 49.5 9.2 20.1 23.9 36.4 33.7 23.9
115 76 80 52 88 81 9 25 39 52 73 53
62.2 41.1 43.2 28.1 47.6 43.8 4.9 13.5 21.1 28.1 39.5 28.6
233 161 147 109 180 172 26 62 83 119 135 97
63.1 43.6 39.8 29.5 48.8 46.6 7.0 16.8 22.5 32.2 36.6 26.3
.695 .322 .180 .546 .640 .275 .101 .09 .515 .088 .25 .301
Note. SFA = Saturated fatty acids; MUFA = Monounsaturated fatty acids; PUFA = Polyunsaturated fatty acids; P/S = Polyunsaturated fatty acids/Saturated fatty acids; CSI = Cholesterol/Saturated fatty acids.
respectively (Fakhori et al. 2012). In older Turkish adults, the obesity prevalence is also rising, reported as 48.7% in a study by S¸ imsek and colleagues (2014) with adults over 65 years of age. According to the results of the TEKHARF and METSAR studies in Turkey, the prevalence of obesity (BMI ≥ 30.0 kg/m2 ) was higher in women than in men aged 60 years and older (O˘guz et al. 2008; Onat 2003). In a study in Sivas (a central Anatolian city) in 2005, the prevalence of obesity (BMI ≥ 30.0 kg/m2 ) was 24.8% in people aged 65 years and over: 39.5% in women and 9.5% in men (Özdemir et al. 2005). Body weights and heights of women were less than those of men, however, their BMIs were higher in this study (p 30% of total energy; in addition, 43.6% reported a high intake of SFA, which, together with 29.5% of elderly adults, shows a low intake of PUFA; and about 40.0% of elderly show a low intake of MUFA. These findings indicate a potential risk of atherosclerosis in Turkish elderly due to diet. This characteristic is clearly demonstrated by the P/S ratio, which is < 1 (48.8%). In many studies, a balanced intake of dietary PUFA and SFA was thought to be very important in regulating serum cholesterol (Clarke et al. 1997; Muller et al. 2003; Siri-Tarino et al. 2010). However, excessive intake of PUFA has undesirable effects such as oxidative stress due to high susceptibility to lipid peroxidation (Kang et al. 2005). Moderate evidence from epidemiologic studies relates dietary cholesterol intake to clinical CVD end-points (ATP III 2002; Greene et al. 2005). It is known that reducing cholesterol intakes decreases serum LDL cholesterol in most persons (ATP III 2002). Current dietary guidance in general recommends a diet that contains < 300 mg of cholesterol per day (KrisEtherton 2001). With regard to this recommendation, the daily dietary cholesterol intakes of the 46.6% of the elderly in this study were more than 100 mg/1,000 kcal. Mean values of daily cholesterol intakes of men and women were 179.9 ± 148.2 and 163.1 ± 149.6 mg, respectively. The results are comparable with another study held in Turkey revealing that the dietary cholesterol intakes were 186.6 ± 126.8 mg and 180.2 ± 141.2 mg in elderly men and women, respectively (Ongan 2012). Epidemiological and population studies reported that some micronutrients may beneficially affect CVD risk (i.e., antioxidant vitamins such as vitamin E, vitamin C, and β-carotene) (Osganian et al. 2003; Padayatty et al. 2003; Tribble 1999). Substantial interest in this topic was stimulated initially by findings in preclinical settings, showing that antioxidant vitamins can help scavenge highly reactive free radicals and inhibit lipid peroxidation. Scavenging of free radicals may slow down or prevent the development of atherosclerosis (Chattopadhyay and Bandyopadhyay 2006; Padayatty et al. 2003). For example, dietary recommended intake for vitamin E is 15 mg
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TE/day (Subcommittee on the Tenth Edition of the RDAs 1989). Inadequate intake ratios of vitamin E in elderly men and women were 23.9% and 21.1%, respectively (table 3). Volkert and colleagues (2004) had similar results, showing that vitamin E intakes were inadequate in elderly adults. Marshall and colleagues (2001) reported that 60% of the elderly participants in their study had intakes below RDA. Previous studies have reported 17% to 48% of older adults with vitamin E intakes at levels below two thirds of the RDAs (Payette and Gray-McDonald 1991; Ryan, Craig, and Finn 1992). In elderly adults, excess intake of PUFA can cause malfunction in immunity due to Tcell activity. It is known that vitamin E intake prevents this malfunction by increasing the formation of lipid peroxidase via PUFA (Chattopadhyay and Bandyopadhyay 2006). Daily vitamin E requirement can be supplied by adequate intake of vegetable oils, nuts, peanut butter, and wheat germ along with whole grains. Whole or unrefined grains provide fiber and other nonnutritive components which are associated with reduced risk of CVD (Millen et al 1996; Slavin, Jacobs, and Marquat 1997). Since enriched and fortified grain foods provides additional sources of vitamin B and improve intake of vitamin E and fiber, older adults should be encouraged to select whole grain (Slavin et al. 1997; Yates et al. 1998). Many observational and experimental studies have examined the relation between dietary fiber and cardiovascular risk factors. The protective effect of dietary fiber on risk of CVD and CVD is biologically plausible, and there are many potential mechanisms through which fiber may act on individual risk factors (Slavin et al. 1997). One of the AHA recommendations is to increase fiber intake in the diet. This goal can be achieved by the guidelines for food consumption focusing on vegetables, cereals, grains, and fruits (KrisEtherton 2001). It is reported that a high-fiber diet has a hypocholesterolemia effect (Kishimoto et al. 1995). Prospective cohort studies have consistently found an inverse association between fiber intake and risk of CVD (Eshak et al. 2010; Kishimoto et al. 1995; Slavin et al. 1997). In this study daily dietary fiber intake was 21.8 ± 8.6 g, 23.2 ± 11.1 g in men and women, respectively. According to the recommendations on fiber for elderly men and women are 29 g/day, 21 g/day respectively (Subcommittee on the Tenth Edition of the RDAs 1989), the fiber intakes of 20.1% of men and 13.5% of women were below the recommended levels in this study. In other studies held on elderly, the fiber intakes are between the amount of 17.2–29.9 g/day (Gezmen-Karadag et al. 2012; Nowson et al. 2003; Wu et al. 2013). The increased level of homocysteine (hcy) is expressed as an independent risk factor of development of CVD (Bostom et al. 1999). Desirable range of hcy in healthy individuals is between 5–15 μmol/L. CVD risk is increased by every amount of 5 μmol/L rising with a rate of 1.6 to1.8 times (Dalery et al. 1995; Hoogeveen et al. 1998). Vitamin B6 , B12, and folate are primary factors affecting the hcy metabolism (Bostom et al. 1999). It is determined
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that the main factor causing to hyperhomosisteinemia is deficiency in folic acid. Individuals having low serum folic acid levels were intended to have higher Hcy levels in plasma (Lindeman et al. 2003). Of the elderly adults surveyed in this study, 26.3% were found to have an inadequate folate intake (table 3). Several other studies reported intakes of dietary folate at levels below two thirds the RDA among 28%–84% of older adult populations (Garry et al. 1982; McGandy et al. 1986; Payette et al. 1991). Folate is naturally existent in orange juice, dark green leafy vegetables, peanuts, strawberries, dried beans and peas, and asparagus, among other foods. To achieve a low level of homocysteine, it is recommended that older adults consume an adequate amount of foods that are both rich in folate and low in fat (e.g., skimmed milk and low-fat dairy products). As a consequence of consuming these products, the CVD risk drops 7%–9% (Appel et al. 2000). In this study, elderly adults were found to have 32.2% of the recommended intake of vitamin B6 and 36.6% of B12 (table 3). As a comparison, studies in both Germany (Paker-Eichelkraut et al. 2013) and Holland (de Groot et al. 1999) found elderly adults to have an inadequate intake of B6 and B12 . Vitamin B12 deficiency occurs in 12%–14% of community-dwelling in people > 60 years of age and in up to 25% of institutionalized older people (Krasinski et al. 1986). A deficiency of vitamin B12 can cause an increased level of homocystine, which increases one’s risk of CVD (Dalery et al. 1995). Çitak-Akbulut and Ersoy (2008) pointed out that adequate and balanced nutrition is an important contributor toward a healthy life for elderly people. These researchers also indicated the necessity of assessing nutritional status in appropriate intervals, so as to monitor risk factors that could adversely affect nutrition and prevent future health problems.
CONCLUSION In conclusion, it was found that the SFA intake of elderly was high, and the intakes of fiber, vitamin E, vitamin B6 , vitamin B12 , and folate were inadequate for over 20% of those surveyed. The importance of ensuring adequate vitamin and mineral intake increases for elderly adults, due to a decline in their physical activity and energy expenditure, increased immune system impairment, and the burden of chronic diseases. An inadequate intake of vitamins and minerals can increase the severity of acute and chronic diseases that lead to death among elderly adults (Akıcı et al. 2001). Unless an impairment of health occurs from problems with digestion, absorption, or food consumption, vitamin and mineral requirements (with the exception of vitamin D) could be supplied by an adequate and balanced diet. As a consequence, it is clear that education for the elderly about balanced and adequate nutrition is needed to prevent diet-related risks to cardiovascular health. In addition to dietary factors, the age-related
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incline in the use of drugs for chronic diseases among elderly adults must be taken into account. In sum, age-related disabilities affecting physical activity, digestion, diet, and drug interactions can all affect the absorption of nutrients in elderly adults.
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Determination of Dietary Status as a Risk Factor of Cardiovascular Heart Disease in Turkish Elderly People a
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Alev Keser , Nurcan Yabanci Ayhan , Pelin Bilgiç , Muhittin Tayfur & Işil ŞImşek
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Department of Nutrition and Dietetics, Ankara University, Ankara, Turkey b
Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey c
Department of Nutrition and Dietetics, Başkent University, Ankara, Turkey
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Basic Pharmaceutical Sciences, Gazi University, Ankara, Turkey Published online: 20 Jan 2015.
To cite this article: Alev Keser, Nurcan Yabanci Ayhan, Pelin Bilgiç, Muhittin Tayfur & Işil ŞImşek (2015) Determination of Dietary Status as a Risk Factor of Cardiovascular Heart Disease in Turkish Elderly People, Ecology of Food and Nutrition, 54:4, 328-341, DOI: 10.1080/03670244.2014.992520 To link to this article: http://dx.doi.org/10.1080/03670244.2014.992520
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Ecology of Food and Nutrition, 54:328–341, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.992520
Determination of Dietary Status as a Risk Factor of Cardiovascular Heart Disease in Turkish Elderly People ALEV KESER and NURCAN YABANCI AYHAN Department of Nutrition and Dietetics, Ankara University, Ankara, Turkey
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PELIN BILGIÇ Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
MUHITTIN TAYFUR Department of Nutrition and Dietetics, Ba¸skent University, Ankara, Turkey
I¸SIL S¸ IM¸SEK Basic Pharmaceutical Sciences, Gazi University, Ankara, Turkey
This study was performed to determine the status of diet as a risk factor of cardiovascular heart disease in a group of Turkish elderly people. We performed a cross-sectional study using the data of voluntary participants aged between 65–74 years old. Participants completed 3-day diet records. Of participants, 64.1% of the men and 62.2% of the women reported their daily dietary fat intake as being > 30% of total energy (p > .05). More than 20% of these elderly respondents’ daily intakes of vitamin E, vitamin B6 , vitamin B12 , and folate were found to be under the recommended values. As a result, the total fat intake of these elderly people was found to be high; while their intake of fiber and vitamin B6 , vitamin B12 were found to be low, compared to American Heart Association recommendations. In conclusion, it is recommended that developing sufficient and balanced diets may decrease cardiovascular risk factors. KEYWORDS cardiovascular risk factors, diet, elderly, nutrient intake
Address correspondence to Nurcan Yabancı Ayhan, Department of Nutrition and Dietetics, Ankara University, Aktas Kav¸sa˘gı No. 5, 06340 Ankara, Turkey. E-mail: nyabanci@ gmail.com 328
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The population of adults over 65 years of age is growing rapidly worldwide. In 2009, 21% of the population in developed countries was aged over 60 years, and it is projected that by 2050 the proportion of those over 60 years of age will have increased to 33% (Department of Economic and Social Affairs 2009). According to the Turkish Statistical Institute, the elderly population ratio in Turkey was 7.7% in 2007 and it is estimated to rise to 10.2% in 2023, 20.8% in 2050, and 27.7% in 2075 due to projected population; Turkey is thus predicted to be among the countries having an elderly population in a very high ratio in the future (TÜI˙ K 2013). Cardiovascular diseases (CVD) are among the serious public health problems in Turkey. Over 230,000 new coronary cases occur in a year, according to the study Cardiovascular Diseases and their Risk Factors in Turkish Adults. This study also indicates that in Turkey approximately 160,000 men and 120,000 women die each year, and of these the deaths of 61,000 men and 66,000 women are coronary originate (Onat et al. 1996). Risks for CVD also increase by age (Stanner 2009). The prevalence of coronary heart diseases is one in five elderly adults between 60–69 years of age, and one in four elderly adults aged 70 years and over (Onat et al. 1996). Dietary intake is thought to exert a great influence on the risk of CVD. Because lifestyle factors such as smoking, physical activity, and nutrition play important roles in the onset and progress of CVD, they may be especially important in the elderly, who are at an increased risk of developing chronic diseases (de Groot at al. 2004). Results of some studies indicated that interventions to change nutritional habits can be highly effective in reducing CVD risk. Diets low in saturated fat and cholesterol are associated with lower rates of CVD. Replacing saturated with polyunsaturated fatty acids (PUFA) reduced cardiovascular events in some early trials. Folate, vitamins E, B6, B12, and dietary fiber are emerging as potentially useful protective factors (Fung et al. 2004; Liu et al. 2000). The American Heart Association (AHA) guidelines, in their revised form, advocate a limitation of saturated fatty acids (SFA) to less than 10% of total energy, and daily consumption of total cholesterol to less than 300 mg. The AHA guidelines also provide recommendations for several other parameters, including fiber (10 g/1000 kcal). AHA has made some suggestions about nutrition and lifestyle to reduce the CVD risks (Kris-Etherton et al. 2001). This study was planned to evaluate the cardiovascular risk factors according to AHA depending on diet in a group of Turkish elderly people.
METHODS Participants A cross-sectional study was conducted on total of 369 elderly people (184 men, 185 women), between the ages of 65–74 (68.3 ± 2.8) years.
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Participants live in the district of Emek and Bahcelievler/Ankara where the elderly population is high. Data were collected by face-to-face interviews between September and December 2011. All participants were healthy by point of cognitive function (no participant had any cognitive or health problem that would affect the responses). All studies were conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Ethics Committee of Gazi University (Ethics approval code 2011/219). Written informed consent was obtained from all study participants.
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Anthropometric Measurements Weight was measured by electronic scales to the nearest 0.1 kg and height was measured to the nearest 0.1 cm a wall-mounted stadiometer while participants were wearing light clothing and no shoes. Body mass index (BMI) (kg/m2 ) was evaluated (classified) according to World Health Organization (WHO) standards. Underweight was diagnosed when the BMI was less than 18.5 kg/m2 ; normal weight when the BMI was between 18.5–24.9 kg/m2 ; whereas overweight was diagnosed when the BMI was between 25.0–29.9 kg/m2 ; and when BMI exceeded 29.9 kg/m2 , then participants were classified as obese (WHO 1997).
Nutritional Assessment The participants and their family members were taught by the dietitian how to keep accurate food records. The first day of the record consisted of a 24-hour recall which was used to instruct participants in the degree of detail needed for the record. Participants recorded accurately and completely the type and quantity of all foods and liquids consumed, as well as recipes for prepared food items and method of food preparation. On rare occasions when it was not possible to weigh food, consumed serving size was estimated from either product names, the place of food consumption, standard weights of food items or from the portion size that was determined from a picture booklet of 120 photographs of foods (Rakıcıo˘glu et al. 2009). Participants recorded the type and quantity of food and beverages consumed for 2 weekdays and 1 weekend day, which were consecutive; in total, 3-day food intake records were obtained from each participant. The accuracy and completeness of the food records were checked and completed by dietitians and participants. The average energy (kcal), total fat, saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), dietary cholesterol and fiber, vitamins E, B6 , B12, and folate intakes were analyzed using BeBI˙ S 6.1 software (Nutrition Information System), which
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is based on several international and national food-composition tables. The energy and nutrient intakes of the participants were compared to the Recommended Dietary Allowances (RDA) (Subcommittee on the Tenth Edition of the RDAs 1989), Dietary Reference Intake (DRI) (Yates, Schicker, and Suilor 1998), and AHA recommendations (Kris-Etherton et al. 2001). The atherogenic indexes of polyunsaturated fatty acids–saturated fatty acids ratio (P/S) and cholesterol-saturated fat index (CSI) (NCEP 1992) were determined using the following equations: P/S: (total PUFA/total SFA); CSI: (0.01 xg SFA) + (0.05 xmg cholesterol) (Connor et al. 1989).
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Statistical Analyses Data were analyzed by using SPSS statistical software package. Continuous variables were described by using mean± standard deviations. Frequencies and percentages were used as descriptive statistics for categorical variables. Normally distributions were evaluated by one sample Kolmogorow Smirnov test. Inter-group comparisons performed with Chi-square and t-tests; and the statistically significant p level was set at .05.
RESULTS The average age of the elderly people in the study was 68.3 ± 2.8 years for the men, and 68.1 ± 2.8 years for the women. While weight and height were higher for men than women (p < .001), BMI was higher for women than men (p < .05). The prevalence of obesity was 17.4% in men, 23.8% in women (table 1). Daily dietary energy, the percentages of energy from total fats, SFA, and MUFA, dietary cholesterol, and vitamin E intake were higher in men than women (p > .05). In addition to these, vitamin B12 intake is statistically higher in men (3.5 ± 3.3 mcg) than in women (2.6 ± 3.4 mcg) (p < .05) (table 2). The percentage of elderly exceeding the dietary recommendations of the AHA for total fat, fatty acids, and dietary cholesterol is presented in table 3. In addition, the percentage of elderly who did not meet two thirds of RDA for vitamin E, vitamin B6 , and folate and the recommendation for dietary fiber is presented. According to the recommendation of AHA, risk factors related to dietary intakes were higher in men except for MUFA, vitamin B12, and folate. Total fat intake of 63.1% of the elderly adults in this study was high, dietary cholesterol intake of 46.6% of participants was over the recommendations of AHA, and there was no gender difference (p > .05).
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TABLE 1 The Evaluation of Age, Weight, Height, BMI, and Obesity Prevalence according to Gender
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Age (y) Weight (kg) Height (cm) BMI (kg/m2 )
Underweight Normal weight Overweight Obesity ∗
Men (n = 184) Mean ± SD
Women (n = 185) Mean ± SD
p
68.3 ± 2.8 75.7 ± 10.9 169.5 ± 7.5 26.3 ± 3.4
68.1 ± 2.8 69.4 ± 12.7 159.2 ± 6.8 27.4 ± 4.8
.446 .00∗ .00∗ .019∗
Men (n = 184)
Women (n = 185)
Total (N = 369)
n
%
2 66 84 32
1.1 35.9 45.7 17.4
n 1 62 78 44 χ 2 = 2.573, p
%
N
%
0.5 33.5 42.2 23.8 = .462
3 128 162 76
0.8 34.7 43.9 20.6
p < .05.
TABLE 2 Mean Values of Daily Energy and Nutrient Intake according to Gender Energy and nutrient
Men (n = 184) Mean ± SD
Women (n = 185) Mean ± SD
Total (N = 369) Mean ± SD
p
Energy (kcal) Total fat (TE%) SFA (TE%) MUFA (TE%) PUFA (TE%) P/S CSI Dietary cholesterol (mg) Fiber (g) Vitamin E (mg TE) Vitamin B6 (mg) Vitamin B12 (mcg) Folate (mcg)
1645.8 ± 15.4 34.9 ± 10.9 10.4 ± 4.3 11.8 ± 4.1 10.8 ± 6.1 1.2 ± 0.7 10.7 ± 9.6 179.9 ± 148.2 21.8 ± 8.6 22.1 ± 16.2 1.4 ± 0.5 3.5 ± 3.3 348.5 ± 121.2
1585.9 ± 575.9 33.7 ± 10.5 9.9 ± 4.0 11.0 ± 4.3 10.8 ± 6.0 1.3 ± 0.9 9.9 ± 9.4 163.1 ± 149.6 23.2 ± 11.1 21.7 ± 20.8 1.4 ± 0.6 2.6 ± 3.4 356.2 ± 131.1
1615.7 ± 95.9 34.4 ± 10.7 10.2 ± 4.2 11.4 ± 4.2 10.8 ± 6.0 1.2 ± 0.8 10.3 ± 9.4 171.5 ± 148.9 22.5 ± 9.9 21.9 ± 18.7 1.4 ± 0.6 3.0 ± 3.4 352.3 ± 126.2
.335 .260 .357 .066 .983 .412 .407 .277 .180 .829 .401 .007∗ .556
Note. SFA = Saturated fatty acids; MUFA: = Monounsaturated fatty acids; PUFA = Polyunsaturated fatty acids; P/S = Polyunsaturated fatty acids/Saturated fatty acids; CSI = Cholesterol-saturated fat index. ∗ p < .05.
DISCUSSION In Turkey, 48% of all deaths are related to CVD (Sa˘glık Bakanlı˘gı 2006). Obesity as an important factor of CVD was also supported by a study by Kvamme and colleagues (2010) on adults over the age of 65. In recent years, the rise in obesity is alarming. The prevalence of obesity in Americans 65–74 years old is 41.5% and 40.3% in men and women,
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TABLE 3 Percentage of Elderly People Not Meeting AHA Recommendations for Cardiovascular Disease Prevention Men (n = 184)
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Dietary risk factors Total fat > 30% TE SFA > 10% TE MUFA < 10% TE PUFA < 7% TE P/S < 1 Cholesterol > 100 mg/1,000 kcal CSI > 25 Fiber < 10 g/1,000 kkal Vitamin E < 2/3 RDA Vitamin B6 < 2/3 DRI Vitamin B12 < 2/3 DRI Folate < 2/3 DRI
Women (n = 185)
Total (N = 369)
n
%
n
%
N
%
p
118 85 67 57 92 91 17 37 44 67 62 44
64.1 46.2 36.4 31.0 50.0 49.5 9.2 20.1 23.9 36.4 33.7 23.9
115 76 80 52 88 81 9 25 39 52 73 53
62.2 41.1 43.2 28.1 47.6 43.8 4.9 13.5 21.1 28.1 39.5 28.6
233 161 147 109 180 172 26 62 83 119 135 97
63.1 43.6 39.8 29.5 48.8 46.6 7.0 16.8 22.5 32.2 36.6 26.3
.695 .322 .180 .546 .640 .275 .101 .09 .515 .088 .25 .301
Note. SFA = Saturated fatty acids; MUFA = Monounsaturated fatty acids; PUFA = Polyunsaturated fatty acids; P/S = Polyunsaturated fatty acids/Saturated fatty acids; CSI = Cholesterol/Saturated fatty acids.
respectively (Fakhori et al. 2012). In older Turkish adults, the obesity prevalence is also rising, reported as 48.7% in a study by S¸ imsek and colleagues (2014) with adults over 65 years of age. According to the results of the TEKHARF and METSAR studies in Turkey, the prevalence of obesity (BMI ≥ 30.0 kg/m2 ) was higher in women than in men aged 60 years and older (O˘guz et al. 2008; Onat 2003). In a study in Sivas (a central Anatolian city) in 2005, the prevalence of obesity (BMI ≥ 30.0 kg/m2 ) was 24.8% in people aged 65 years and over: 39.5% in women and 9.5% in men (Özdemir et al. 2005). Body weights and heights of women were less than those of men, however, their BMIs were higher in this study (p 30% of total energy; in addition, 43.6% reported a high intake of SFA, which, together with 29.5% of elderly adults, shows a low intake of PUFA; and about 40.0% of elderly show a low intake of MUFA. These findings indicate a potential risk of atherosclerosis in Turkish elderly due to diet. This characteristic is clearly demonstrated by the P/S ratio, which is < 1 (48.8%). In many studies, a balanced intake of dietary PUFA and SFA was thought to be very important in regulating serum cholesterol (Clarke et al. 1997; Muller et al. 2003; Siri-Tarino et al. 2010). However, excessive intake of PUFA has undesirable effects such as oxidative stress due to high susceptibility to lipid peroxidation (Kang et al. 2005). Moderate evidence from epidemiologic studies relates dietary cholesterol intake to clinical CVD end-points (ATP III 2002; Greene et al. 2005). It is known that reducing cholesterol intakes decreases serum LDL cholesterol in most persons (ATP III 2002). Current dietary guidance in general recommends a diet that contains < 300 mg of cholesterol per day (KrisEtherton 2001). With regard to this recommendation, the daily dietary cholesterol intakes of the 46.6% of the elderly in this study were more than 100 mg/1,000 kcal. Mean values of daily cholesterol intakes of men and women were 179.9 ± 148.2 and 163.1 ± 149.6 mg, respectively. The results are comparable with another study held in Turkey revealing that the dietary cholesterol intakes were 186.6 ± 126.8 mg and 180.2 ± 141.2 mg in elderly men and women, respectively (Ongan 2012). Epidemiological and population studies reported that some micronutrients may beneficially affect CVD risk (i.e., antioxidant vitamins such as vitamin E, vitamin C, and β-carotene) (Osganian et al. 2003; Padayatty et al. 2003; Tribble 1999). Substantial interest in this topic was stimulated initially by findings in preclinical settings, showing that antioxidant vitamins can help scavenge highly reactive free radicals and inhibit lipid peroxidation. Scavenging of free radicals may slow down or prevent the development of atherosclerosis (Chattopadhyay and Bandyopadhyay 2006; Padayatty et al. 2003). For example, dietary recommended intake for vitamin E is 15 mg
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TE/day (Subcommittee on the Tenth Edition of the RDAs 1989). Inadequate intake ratios of vitamin E in elderly men and women were 23.9% and 21.1%, respectively (table 3). Volkert and colleagues (2004) had similar results, showing that vitamin E intakes were inadequate in elderly adults. Marshall and colleagues (2001) reported that 60% of the elderly participants in their study had intakes below RDA. Previous studies have reported 17% to 48% of older adults with vitamin E intakes at levels below two thirds of the RDAs (Payette and Gray-McDonald 1991; Ryan, Craig, and Finn 1992). In elderly adults, excess intake of PUFA can cause malfunction in immunity due to Tcell activity. It is known that vitamin E intake prevents this malfunction by increasing the formation of lipid peroxidase via PUFA (Chattopadhyay and Bandyopadhyay 2006). Daily vitamin E requirement can be supplied by adequate intake of vegetable oils, nuts, peanut butter, and wheat germ along with whole grains. Whole or unrefined grains provide fiber and other nonnutritive components which are associated with reduced risk of CVD (Millen et al 1996; Slavin, Jacobs, and Marquat 1997). Since enriched and fortified grain foods provides additional sources of vitamin B and improve intake of vitamin E and fiber, older adults should be encouraged to select whole grain (Slavin et al. 1997; Yates et al. 1998). Many observational and experimental studies have examined the relation between dietary fiber and cardiovascular risk factors. The protective effect of dietary fiber on risk of CVD and CVD is biologically plausible, and there are many potential mechanisms through which fiber may act on individual risk factors (Slavin et al. 1997). One of the AHA recommendations is to increase fiber intake in the diet. This goal can be achieved by the guidelines for food consumption focusing on vegetables, cereals, grains, and fruits (KrisEtherton 2001). It is reported that a high-fiber diet has a hypocholesterolemia effect (Kishimoto et al. 1995). Prospective cohort studies have consistently found an inverse association between fiber intake and risk of CVD (Eshak et al. 2010; Kishimoto et al. 1995; Slavin et al. 1997). In this study daily dietary fiber intake was 21.8 ± 8.6 g, 23.2 ± 11.1 g in men and women, respectively. According to the recommendations on fiber for elderly men and women are 29 g/day, 21 g/day respectively (Subcommittee on the Tenth Edition of the RDAs 1989), the fiber intakes of 20.1% of men and 13.5% of women were below the recommended levels in this study. In other studies held on elderly, the fiber intakes are between the amount of 17.2–29.9 g/day (Gezmen-Karadag et al. 2012; Nowson et al. 2003; Wu et al. 2013). The increased level of homocysteine (hcy) is expressed as an independent risk factor of development of CVD (Bostom et al. 1999). Desirable range of hcy in healthy individuals is between 5–15 μmol/L. CVD risk is increased by every amount of 5 μmol/L rising with a rate of 1.6 to1.8 times (Dalery et al. 1995; Hoogeveen et al. 1998). Vitamin B6 , B12, and folate are primary factors affecting the hcy metabolism (Bostom et al. 1999). It is determined
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that the main factor causing to hyperhomosisteinemia is deficiency in folic acid. Individuals having low serum folic acid levels were intended to have higher Hcy levels in plasma (Lindeman et al. 2003). Of the elderly adults surveyed in this study, 26.3% were found to have an inadequate folate intake (table 3). Several other studies reported intakes of dietary folate at levels below two thirds the RDA among 28%–84% of older adult populations (Garry et al. 1982; McGandy et al. 1986; Payette et al. 1991). Folate is naturally existent in orange juice, dark green leafy vegetables, peanuts, strawberries, dried beans and peas, and asparagus, among other foods. To achieve a low level of homocysteine, it is recommended that older adults consume an adequate amount of foods that are both rich in folate and low in fat (e.g., skimmed milk and low-fat dairy products). As a consequence of consuming these products, the CVD risk drops 7%–9% (Appel et al. 2000). In this study, elderly adults were found to have 32.2% of the recommended intake of vitamin B6 and 36.6% of B12 (table 3). As a comparison, studies in both Germany (Paker-Eichelkraut et al. 2013) and Holland (de Groot et al. 1999) found elderly adults to have an inadequate intake of B6 and B12 . Vitamin B12 deficiency occurs in 12%–14% of community-dwelling in people > 60 years of age and in up to 25% of institutionalized older people (Krasinski et al. 1986). A deficiency of vitamin B12 can cause an increased level of homocystine, which increases one’s risk of CVD (Dalery et al. 1995). Çitak-Akbulut and Ersoy (2008) pointed out that adequate and balanced nutrition is an important contributor toward a healthy life for elderly people. These researchers also indicated the necessity of assessing nutritional status in appropriate intervals, so as to monitor risk factors that could adversely affect nutrition and prevent future health problems.
CONCLUSION In conclusion, it was found that the SFA intake of elderly was high, and the intakes of fiber, vitamin E, vitamin B6 , vitamin B12 , and folate were inadequate for over 20% of those surveyed. The importance of ensuring adequate vitamin and mineral intake increases for elderly adults, due to a decline in their physical activity and energy expenditure, increased immune system impairment, and the burden of chronic diseases. An inadequate intake of vitamins and minerals can increase the severity of acute and chronic diseases that lead to death among elderly adults (Akıcı et al. 2001). Unless an impairment of health occurs from problems with digestion, absorption, or food consumption, vitamin and mineral requirements (with the exception of vitamin D) could be supplied by an adequate and balanced diet. As a consequence, it is clear that education for the elderly about balanced and adequate nutrition is needed to prevent diet-related risks to cardiovascular health. In addition to dietary factors, the age-related
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incline in the use of drugs for chronic diseases among elderly adults must be taken into account. In sum, age-related disabilities affecting physical activity, digestion, diet, and drug interactions can all affect the absorption of nutrients in elderly adults.
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